April 21, 2025

Top Questions from the Exploring IME & GME: Hospital Reimbursement & Revenue Integrity Perspectives Webinar

Looking for more information about Exploring IME & GME: Hospital Reimbursement & Revenue Integrity Perspectives? Christina Brown, Director of Reimbursement Services, and Olga Barone-Allan, Director of Revenue Integrity, answer your questions from the recent webinar.

To watch the Exploring IME & GME: Hospital Reimbursement & Revenue Integrity Perspectives Webinar, click HERE.

1. 1. 1. 1. When you say info only bill, does that mean with 04 condition code only?
        
        Inpatient Prospective Payment System (PPS) hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs) must submit two claims for inpatient stays by Medicare Advantage beneficiaries. Sometimes called “shadow billing,” these claims must be filed with both the MA and the A/B MAC or FI so that the inpatient days to be captured and included in the disproportionate share and low-income patient (LIP) calculations. The information also is used for computation of the hospital’s Indirect Medical Education payment.
        
        If a hospital meets the disproportionate share hospital definition, an additional operating cost payment will be made for discharges. The LIP adjustment accounts for differences in costs among IRFs associated in the proportion of low-income patients treated. Additional information about the calculations can be found in CMS Change Request (CR) 5647.
        
        The claims should be submitted as covered, and should include the following:
        
        Type of bill 11X
        Condition code 04 (information only bill)
        Condition code 69 (teaching hospitals only – code indicates a request for a supplemental payment for Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
        
        Do you have anything from CMS or a MAC stating they will incorporate the results of Hershey v Becerra (DGME weighting issue) into any open cost reports, or if there is a valid reopening for another issue they will also process? Reason I ask is we are getting partial denials (for this issue) on our 2019 cost report reopenings that have other valid reasons for a reopening (i.e. IME & DSH). I understand this case by itself is not a valid reason for the MAC to accept a reopening request.
        
        We have not received anything from CMS officially on this. The rule was very explicit in that fact that it would not be effective retroactively. I would think if you are reopening for other reasons, this could be adjusted, but it may depend on the MAC. My understanding is there is firm ground for not allowing if this issue was not protested or appealed.
        
        With regard to MA plans, what do you mean by cleaning up IME billing (slide 43)?
        
        Be cognizant that you are billing appropriately for all applicable days. This is what Olga was talking about. Consider having an outside firm, such as BESLER, that can do a second pass with claims.
        
        Do IME claims need to be submitted for SNF?
        
        Skilled Nursing Facilities/Swing Bed Units
        To maintain correct benefit period information, SNFs and swing bed units must submit claims to the AB MAC/FI in addition to the claims they submit to the MA plans so long as the beneficiary remains at a skilled level of care. The coding used on these claims will allow the AB MAC/FI to override edits requiring prior qualifying stay data so the skilled days can be added to the Common Working File.
        
        The claims should be submitted as covered, and should include the following:
        
        Type of Bill 21X or 18X
        Condition Code 04
        The condition code will indicate that the claim is being submitted for information only, and the FI/MAC will not issue payment in addition to the amount paid by the MA plan.
        
        Do MA plans reimburse DGME?
        
        No, MA plans do not reimburse DGME inpatient, however they do pay for MA addon Nursing & allied Health.
        
        Line 16 Initial Year – do we have wait until the 6th year of the programs?
        
        Per the PRM section 4030.1: For urban hospitals that began participating in training residents in a new program for the first time on or after October 1, 2012, under 42 CFR 413.79(e)(1), include FTE residents in a new program on this line if this cost reporting period is prior to the cost reporting period that coincides with or follows the start of the sixth program year of the first new program started (see 79 FR 50110 (August 22, 2014)). For rural hospitals participating in a new program(s) on or after October 1, 2012, under 42 CFR 413.79(e)(3), include FTE residents in a particular new program on this line if this cost reporting period is prior to the cost reporting period that coincides with or follows the start of the sixth program year of that new program (see 79 FR 50110 (August 22, 2014)).
        
        Will you address overlap FTE count issues? What is the recourse when an overlap occurs, but the facility which needs to grant a release has gone bankrupt?
        
        We did not go to this level of detail for this webinar. If you count the FTEs, there is always a possibility of audit where you would have to prove what is being claimed to the MAC. You should seek outside council if it is a concern.
        
        IME payment from CMS for inpatient and then MA plan downgrades to observation, does the IME get returned to CMS?
        
        Because Observation is considered an outpatient, I would assume IME payment is taken back.
        
        For non teaching hospitals, how are those billed? Are both 04 and 69 applied, and are they covered or noncovered?
        
        Here is how to Submit the appropriate TOB claim with the required condition codes to avoid a rejection.
        
        A) For Teaching Facilities
        Bill type 111
        With Condition Code 04 and 69
        Direct payment is received through the remittance.
        B) For Non-Teaching
        Bill Type 110
        With Condition Code 04
        No direct reimbursement expected however cost report involvement applies.
        C) For INPATIENT REHAB and Units which requires a no pay claim they should use
        a bill type of 111
        with Condition code 04 & the case mix group from the PAI (Patient Assessment).
        There will not be direct reimbursement on this claim; it Impacts the accumulation of Medicare Advantage days for SSI DSH allocation.
        
        What happens when a non-teaching hospital does not submit a shadow bill?
        
        Loss of the additional benefit from Medicare.
        
        WS E-4: Medicare Approved FTEs – How are approved FTEs determined?
        
        You would enter your FTE counts in approved programs; however, the reimbursable amount depends on a number of variables such as FTE cap and as well as any applicable adjustment the facility may qualify to receive. See PRM section 4034.
        
        We have a question regarding GME reporting. We have a skilled nursing facility (BILL TYPE 211-214). We are trying to send shadow claims as type of bill 210.–condition code 04 and 69, all charges in non covered and value code 81. Medicare/Tfile rejects these with error code: 31023. This basically states that the IME should be in COVERED. We then billed as a 210 w/charges in covered and received a denial stating it should be in noncovered.
        
        Skilled Nursing Facilities/Swing Bed Units
        To maintain correct benefit period information, SNFs and swing bed units must submit claims to the AB MAC/FI in addition to the claims they submit to the MA plans so long as the beneficiary remains at a skilled level of care. The coding used on these claims will allow the AB MAC/FI to override edits requiring prior qualifying stay data so the skilled days can be added to the Common Working File.
        
        The claims should be submitted as covered, and should include the following:
        
        Type of Bill 21X or 18X
        Condition Code 04
        The condition code will indicate that the claim is being submitted for information only, and the FI/MAC will not issue payment in addition to the amount paid by the MA plan.
        
        Regarding the past improper proration of weighted GME FTEs, should the MAC adjust improperly prorated FTE amounts for prior and penultimate years as they settle FYs where the calculation is corrected?
        
        That is a point you could argue. However, I would not expect them to make any automatic adjustments, especially if those years were NPR’d.
        
        What are the options for back billing the nonpayment shadow bills that were missed during the year?
        
        Bill them to Medicare before the 1 year timely filing period expires (1 year from discharge date).
        
        How frequently should hospitals engage a third party to review the shadow bill process?
        
        If you hire a vendor that charges by a contingency fee, I would have them in place as a safety net always.
        
        Are resident and fellow FTE treated differently for GME and IME reimbursement?
        
        Residents in their initial residency period (IRP) are counted as 1.0 FTE. Fellows are typically counted as 0.5 FTE if they are beyond that IRP.
        
        CMS pays IME then MA plan denies inpatient stay; is it expected to return CMS IME payment?
        
        The payment is based on the service type and the hospital being a teaching hospital. Any contract or billing issues are irrelevant to Medicare. If the hospital decides to roll it back to a non admit, that is a different story. The MA denying and the hospital doesn’t agree, they are owed that IME money.
        
        If an MA plan denies a claim stating the DRG is not supported, and appeal rights have been full exhausted, are we required to recode the claim so a shadow bill also gets sent to Medicare?
        
        The hospital is entitled to that IME payment. As long as the stay meets inpatient criteria, they are entitled to that money. Providing you feel the claim is correct I don’t think it needs to be changed.
        
        What process do you recommend as best practice for GME payment posting? (Account level or GL?)
        
        You can’t post GME to the account level as it is part of the cost report reimbursement. If by chance they meant the IME, I would highly recommend it gets posted to the account level. With Epic now, it’s pretty neat. They run the 835 and a contractual reversal of the same amount is posted.
        
        With the growth of Advantage, will they pay bad debt similar to traditional Medicare?
        
        That is not likely.