In this episode, we’re pleased to welcome back Andy Sutton, Software Architect at BESLER to share changes to the CMS Intern and Resident Information System, better known as IRIS.
Highlights of this episode include:
- What is IRIS
- Why are they making the changes
- Documenting resident demographics and rotations
- When will these changes go into effect
- Final thoughts
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Andy Sutton, a software architect on the BESLER IT team who specializes in reimbursement software. In this episode, Andy will share changes to the CMS Intern and Resident Information System, better known as IRIS.
Andy Sutton: Hi, Kelly. Thanks for having me on.
Kelly: Thanks for joining us today, Andy. And we’re going to go ahead and just jump in today. There are some changes to IRIS this year. How about providing us with some background information first on it?
Andy: Sure, sure. I’d be happy to. Now, I know it’s never a good idea to start with assumptions, but I think if you’re listening to this, there’s a good chance you have a basic understanding of reimbursing residency programs. But just in case, the very basic premise is that teaching hospitals get a lot of reimbursement or money from the government. It’s basically an incentive so there’s a place for new doctors to learn more about whatever specialty they want to practice in the future. Now, in order to get those reimbursement dollars, they have to fill out fields in their cost report, which it kind of– if you don’t know what a cost report’s kind of like a big tax return for the hospital. Every year, they put it out. It has a bunch of numbers in it. Profits and expenses, things like that. But in that report, there are fields they have to fill out, which are FTE counts and they’re filtered a number of different ways. And in order to document those FTE counts, they have to submit an IRIS, like I said, that’s an Intern and Resident Information System file or, until now, files with their cost report. And those show how they calculated the FTE numbers that they put in the cost report. Now, those files then go through a fiscal intermediary or a MAC, and they use software, and that’s created by CGI STAR Systems that recalculate the FTE counts, and then that is the way they verify the accuracy of the numbers that go on the cost report. And really, that in a nutshell is how you go from having teaching hospital to basically documenting your residents and submission so you get your reimbursement.
Kelly: Okay, great. Thank you for that. And why are they making the changes?
Andy: Well, there’s a few reasons. Now, the first thing is that the files that they used currently, up until now, were all based on old software architecture. So, things like dBASE and DOS, which are totally defunct now. Nobody really uses it anymore. Except in this process, they still are. But that’s going away. So that’s one thing. They want to modernize. So, another thing is they don’t want to over reimburse, right? They don’t want to have to pay out more money than is deserving of the teaching programs. And one of those, the main way that happens is if not on purpose, but if two facilities try to claim the same resident in the same period of time, you can’t do that, right? And that’s considered a conflict. And so this is going to be a giant repository where they’ll be able to check between facilities and make sure that kind of thing doesn’t happen. Now, they did do that in the past, but I think it was a little bit more segmented, regionally. It was a little harder to do. So, they’ll be able to do that a little better. And then one other thing is they’re asking for more information now. Those files that you send in, the use those, like I said, to calculate the FTEs for the numbers that are put into the cost report. And there’s quite a few of them. And all for IRIS. Now, in the past, they could calculate a few of them with the files, but they want to be able to calculate more. So now there will be more fields in the file that facilities submit with their cost report.
Kelly: Thank you for that. And so the file that gets submitted is actually changing, right?
Andy: That’s true. That’s true. So, like I said, the old software system called dBASE was what they used. And in the past, it was two files. There’s an M and an A file, master and assignment. Master was basic demographic information, graduation dates, names, things like that. And then the other file was called assignments, which is synonymous basically with rotations. So, two files, demographics and rotations, and that’s getting changed into an XML file, which still isn’t new architecture. It’s been used a long time. But it’s still in use a lot, and it will bring it down to one file and everything will go into that one file. XML is kind of a hierarchy data file where at the top, it’ll be the facility, the fiscal year, and under that, it’ll have a list of residents, and under each resident, they’ll have the list of rotations. So that’s basically what the new file will look like.
Kelly: Can you go into more specifics of the extra information that teaching hospitals will need to provide?
Andy: Sure. Now, like I said, it’s broken up in kind of two kinds of information. So, the new kind of demographic information is one, very exciting. You have to do a middle name instead of just a middle initial. Yes, very exciting. But a lot of the issues with the old structure was space. So, I think in the past, they kind of did things that they could to save space. Now, you don’t. XML files can be almost as big as you can make them, and software can read giant files. So, no more middle initial. They want the middle name. Now, the other thing, they call this the year one non-IRP residency code. And what that is basically, when a new resident goes to teaching hospital, they do, obviously, a residency. Now, some of them have a full residency period, internal medicine, something like that, and that’s three, four years, whatever that is. But in some situations, they come in and do one year to start. So that would be what they call a transitional year or in some cases they do preliminary medicine or preliminary surgery. And then this one other situation called simultaneous match, which we may or may not need to talk about more. But what they want now is that they always want to be able to know what that first year was. Usually, they do that first year, and then they do whatever full residency they do in the ensuing years of their whole residency. Now, in the past, basically every year, you would send in these files.
And the first year, they would know, “Hey, yeah, they did this first year as a one-year thing before they moved on.” But then in ensuing years, those files would no longer have any reference back to the fact that they did that. So, from now on, they want that. So now it’ll always include that first year of whatever they did, and then it’ll have whatever their current residency code is. And there’s machinations for that on how you calculate the number of years that you get full reimbursement for that particular residency. And then on the side of the rotations, there’s a few as well. Like I said before, there’s a number of fields, and some of them that they couldn’t calculate based on the files in the past, they want to now. One is residents that have rotations at non-provider settings. I feel like I’m doing a lot of definitions during this, but it’s necessary in most cases. So, a non-provider setting basically, a facility has a resident, and sometimes that resident will go out of the hospital to do rotations. Say, a clinic or a doctor’s office. Now, a clinic or a doctor’s office can’t claim that resident for reimbursement the same way as a hospital can. So as long as there’s an agreement in place, the hospital gets to still claim that time for the reimbursement. So that’s called a non-provider setting. So, there’s a field that just has a number of FTEs that residents did at a non-provider setting. So that’s one. Now, two other ones are called inpatient psych and inpatient rehab. Don’t need to do big definitions on that, but they do that basically filtered out into the FTEs that fall into that type of bucket.
Another thing is they now want to know if the resident you are claiming is a displaced resident. So again, displaced resident being, they were at a facility, and something happened there. And I know of a couple that we’ve gone through. I know Hurricane Katrina closed down some hospitals in Louisiana. So those residents went to other places. Sometimes hospitals go out of business. And if it’s a teaching hospital, those residents need somewhere else to be. So, there is, again, a field in the cost report where they need a count of FTEs of their displaced residents, and this is now a way that you couldn’t in the past, now you can calculate those. Another one is new program FTEs. The first year of a program– when a hospital has a new program, the first year it’s considered a new program. That’s weird. Now, but those FTEs also need to be calculated. They go in a different field, and now they’ll be able to do that. And I think that about rounds up most of the important new fields in those files.
Kelly: Wow. That was a lot of great information. Thanks, Andy. Are there any changes that facilities need to know about that might alter the way they’re used to documenting resident demographics and rotations?
Andy: Yeah, there’s a few. Now, one thing is we talk about residencies and residency codes. So, when you’re filling out this file, there’s a code in the file that says what the resident is doing. Now, there’s a lot of these codes that are documented. There’s over 500 of these codes. And in the past, you could use those codes pretty much when needed. But apparently, some of these things I found out in this– we’ve been doing meetings for close to 7 years in doing this whole process. But there’s really a 150 to 170 codes that you’re allowed to use as initial residency code. So that’s not really a change, but they will be looking at that. In the past, they didn’t really verify those things. Now, they will be. And again, with the residency codes, for each code that you use, there is an initial residency period. And basically, that’s determined by the American Medical Association, how many years it should take for a resident to go through a program. Now, the reason that’s important is because whatever that documented number is, as long as that resident’s in that program, they will get reimbursed fully for that time that they’ve decided is the necessary time they need to be proficient in that specialty. Now, that doesn’t always happen. Sometimes, it’ll take longer for a doctor to finish their residency. But once they’re outside of that initial residency period, the hospital only gets half the reimbursement.
Now, why that’s important, in this case, is that those initial residency periods are– now we’re not saying they’re changing, because during this whole process, CMS has told us, “This is what it should have been.” So, some periods are going to be different now than what we were using in the past. Some are a little bit longer, some are a little bit shorter. But there’ll be a little bit different and that needs to be known. Now, we were told on these things, we talked about this, they won’t be going back and checking to see if they were using some value in the past that is no longer true today. But that is something that needs to be known going forward. And then lastly, we’ll bring up the simultaneous match one more time. Simultaneous match is a one-year introduction year. Simultaneous match. So, when they go– when a resident signs up to go to a teaching hospital, they have a residency code or they have one of those three one-year codes that I mentioned, or they can go in and they match. Basically, they do one type of residency the first year, and then for the rest of their residency, they do a different type of residency. And there are actual combinations that need to be used. In the past, I’m not sure how they check this, or if they did check it, but they will be checking it. That you can’t just willy-nilly decide, “Oh, these are the two codes we’re using.” There are actual codes that are used for simultaneous match residence. So I think those would be good things for facilities to know. One other thing that facilities will need to know is kind of the definition of what a conflict is.
Now, in the past, a conflict was basically, “Don’t go more than a 100% of time for any given day in two different facilities.” It kind of makes sense, right? You can’t be in two places for more than a 100% of the time. So, in the past, what would happen would be if a resident was at two facilities– let’s take February just because it’s easily broken up. Let’s say for the month of February, for one week, they were at one facility, and for the other three weeks, they were at a different facility. Now, in the past, what was acceptable and what they actually wanted– again, going back to the whole saving space thing in the old files. What they would do was both of the different facilities would claim the date range of February, right? What is that? January, February, March. 2/1 to 2/28. And then they would put in the percentage of time. So, the one facility would say, “They were at my facility for 75% of the time.” And the other facility would say, “They were at mine for 25% of the time.” Well, that is not what they want you to do anymore. Because we have the space, they want you to break it up. So, say the third week was the one week they were at a different facility. They’re going to want the first two weeks at the first facility at a 100%. That third week at the other facility for a 100%, and the last week at a 100% for the first facility. Now, this could be a challenge for a lot of the hospitals because the way it was done was not like that. They would always use a date range and just say the percentage of time. Now, and this is something that I think we’ll be working out over the year, because in the case that somebody does something– and this happens.
It’s rare, but it happens. They do something on the same day at two different facilities, then obviously, they’re going to need to have that date and a percentage of the time. So, say it was half a day, 50% at one and 50% of the other. So, there’s got to be some kind of wiggle room on the ability to actually have overlapping date ranges with percentages that add up to 100% or less. But in general, now, they want all rotations broken up if there’s any change of location where the reimbursement is at a different place. And that will be a challenge.
Kelly: Fabulous. And when will these changes go into effect?
Andy: Well, they are currently in effect in a way. Now, CMS sent out a memo a couple months ago, and they kind of delineated some of the changes and the start dates for those things. Basically, the two things in effect right now are for any fiscal year end of September 30th, 2022. So that was last year. But it takes time before the cost report. So a lot of people are still working on these things. The requirement is that they submit using the new XML file. That’s the only requirement right now. Now, the other time constraint is starting fiscal year end September 30th, 2023. So the end of this year. At that point, they will start rejecting cost reports if the file that you send in does not calculate correctly to what the fields are in the cost report. So just to kind of go through that one more time. When you send in these files based on what your residents did, you don’t send the actual FTE numbers, the actual full-time equivalent numbers. What you send in is date ranges and percentages of time at your facility or at a place where you get to claim them. So therefore, when the file gets submitted, they use this software, CGI STAR System software, they take that data in there with the percentages, and they recalculate all those numbers. They take the numbers that they recalculated, and they compare it to the cost report numbers in the fields of the summation of those FTE counts.
Now, they need to match, obviously, because you’re using the software to calculate those and put it in the report. They want to be able to use the same numbers and verify that the numbers are the same. Now, they’re kind of giving a one-year bubble, if you will, it seems. And I haven’t heard of anybody actually going through this whole process yet. So, and actually, if anybody listening has any information and wants to talk about their story on how it’s going for them with this new process, I’m sure we’d love to hear about it. So, for a year, they’ll be able to basically make sure this new process is working correctly. Maybe work out kinks, because we did a lot of testing to make sure that the software is calculating correctly. But once you get it out into the real world, facilities have different processes, they do things different. They’re going to be submitting these files and there’s going to be differences. And I think what they want, they want this one first year, they’re not going to just reject cost report because the numbers aren’t adding up. They’re going to say, “Hey, is it a problem with the new system? Do we need to change the way we’re doing things?” Or maybe just as a way that hospitals can feel out the process and make sure they’re doing everything correctly. So for that year, I think there’s going to be a lot of back and forth, making sure all the changes that they’re putting in place are working.
Kelly: Great. Thank you. And any final thoughts for us, Andy?
Andy: Yeah. Well, because of the new process, there were some teaching hospitals out there that could manually do this. They didn’t have to use somebody else’s software or purchase software in order to do this. So, they would basically create a spreadsheet, they’d turn them into a dBASE file, and they could submit it. Well, unless they have programmers on site that have the whole infrastructure to create this new XML file, they won’t be able to. So almost all facilities now will need to use IRIS software going forward. And that’s from the biggest to the smallest facilities out there. And of course, BESLER, we have iRotations, which we use to do that process. But besides that, I think that kind of wraps it up.
Kelly: That’s great. And thank you so much for joining us today, Andy, and for all of this great information.
Andy: Thank you so much for having me, Kelly.
Kelly: And thank you all for joining us for this episode of the Hospital Finance Podcast. Until next time.
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