Blog, Reimbursement

Top Questions from the IME – GME 101 Webinar

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Jeff Wolf

Looking for more information about IME – GME? BESLER Director of Reimbursement Software, Jeff Wolf, answers your questions from the recent webinar. 

To watch Jeff’s IME – GME 101 Webinar, click HERE


  1. Shouldn’t the prior year & penultimate counts be the ‘allowable’ count and not the actual counts meaning if your counts are over the caps, your counts would be the cap?

    Yes. For WS E Pt A, you will need to use the allowable FTE Count from the prior year and penultimate year from the Form 2552-10 line 12 (per Form 2552-10 Instructions).

  2. Which type of beds does Medicare exclude from the IME calculation?

    All exempt units (ex. IPF, IRF, SNF, etc..) including swing bed days and any temporary COVID beds entered into service during the PHE period (Please see the CMS published FAQs and instructions for Form 2552-10.). You should use only the routine bed days from WS S-3 Part I, line 14 Column 3 divided by the number of days in the MCR period (less any temporary COVID bed days as mentioned above). Also, exclude distinct part observation only beds.

  3. For a Psych Affiliation Agreement, where do you enter the FTE amount on Worksheet E-3; Part II? 

    Line 4 per the Form 2552-10 instructions. Be prepared to explain to the MAC the reason for the FTE cap adjustment (have a copy of your Affiliation Agreement handy).

  4. Are most MACs requesting the medical school diplomas during audit in order for facilities to claim the FTEs?

    Not to our knowledge currently, but if your MAC is requesting them, we recommend you have them available.

  5. Can you explain what happens when a cap share specifies IME or GME only?

    This would depend on your Affiliation Agreement with your neighbor, partner or sibling facility and the interpretation of the MAC.

  6. Can you further explain S-2 beginning line 64? The instructions mention base year beginning on or after July 1, 2009, and before June 30, 2010, not the 1996 reference. Is this the section you were referencing for the base year?

    Prior to 2010, providers could not count time residents spent in non-provider settings. This comes from Section 5504 of the ACA. This is the period for rotations in non-provider settings.

  7. Documentation #2 account must be written down to zero. What if the account is removed from AR to a Bad Debt Listing and the account still has a balance? It is no longer in AR?

    Yes, the account can be moved from “Active AR” to “Bad Debt AR”. However, there are a few things that need to be done at the same time. The active AR should have a “Write off” to reduce the AR balance on the Balance Sheet and generate a Debit transaction on the Income statement to show the “write off.” Many providers maintain a “Bad Debt” AR in the event that the patient comes back when they have the financial means to settle the claim. These are considered recoveries of Prior written off Bad Debt, and must be used to reduce your Bad Debt expense in the Current Year Cost Report.

  8. Do you have to claim residents if you have them cycle through your hospital? 

    Typically, yes. Where the rotation is done is where the resident’s time is determined to be counted. I would think you would want to count it at your facility especially if the resident’s specialty is podiatry or dentistry and is an add-on to the cap. Please see the CMS published FAQs for the PHE as there were provisions were made for residents who rotated to non-sponsoring facilities to treat COVID patients.

  9. During the pandemic, some beds were used for COVID-19 patients. Do you count those converted beds in the bed count?

    CMS has instructed facilities not to count these beds for the IME Intern to bed ratios in the CMS published FAQs during the PHE period and the instructions to Form 2552-10.

  10. Explain cap share agreements, especially when only IME or GME is included, but not both.

    The requirements for an Affiliation Agreement can be found at 42 CFR § 413.75. In essence, a Medicare GME Affiliation Agreement means a written, signed, and dated agreement by responsible representatives of each respective hospital in a Medicare GME affiliated group, as defined in this section, that specifies:

    1. The term of the Medicare GME affiliation agreement (at a minimum is one year), beginning on July 1 of a year.

    2. Each participating hospital’s direct and indirect GME FTE caps in effect prior to the Medicare GME affiliation.

    3. The total adjustment to each hospital’s FTE caps in each year that the Medicare GME affiliation agreement is in effect, for both direct GME and IME, that reflects a positive adjustment to one hospital’s direct and indirect FTE caps that is offset by a negative adjustment to the other hospital’s (or hospitals’) direct and indirect FTE caps of at least the same amount.

    4. The adjustment to each participating hospital’s FTE counts resulting from the FTE resident’s (or residents’) participation in a shared rotational arrangement at each hospital participating in the Medicare GME affiliated group for each year the Medicare GME affiliation agreement is in effect. This adjustment to each participating hospital’s FTE count is also reflected in the total adjustment to each hospital’s FTE caps (in accordance with paragraph (3) of this definition

    5. The names of the participating hospitals and their Medicare provider numbers.

    We have noted different MACS have different interpretations of approving cap share agreements and cannot give a definitive answer without seeing the agreement and knowing what the MAC has allowed.

  11. How are you handling instances where ECFMG issue dates were delayed due to COVID and the resident started training prior to the issue date? Are you claiming all of the training time from the start date or just from when the ECFMG was issued?

    Per the CMS Published IRIS Instructions, “Effective June 14, 2004, FMSGs are required to pass Step 1 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) for certification from the ECFMG. Do not use either the issuance date or the English examination date on the ECFMG certificate as the certification date. Instead, use the latest examination date of any other examination as the certification date. For example, if the FMSG passed the CK test on May 15, 2004, and the CS test on July 1, 2004, then the certification date is the later date of July 1, 2004.”

  12. If the first year of the program, do you receive IME payment for general Medicare and Medicare Managed Care if it is a partial year?

    In the first partial year, cost reimbursement includes only Medicare Fee for Service.

  13. If there is an affiliation agreement with another hospital, can the hospital that does not pay the I&R salary claim the FTE?

    Yes, but only in provider-based settings of the affiliated entity. 

  14. Is it possible to have your residency cap amended? 

    We have not seen this. Once the facility’s FTE cap is set by the MAC the only way to increase the FTE Cap is to apply when HHS/CMS adds additional FTE slots.

  15. Should we report all new residency programs on E Part A, Line 6?

    Yes. If the program meets the requirements as a new program under 42 CFR 413.79(e).

  16. What date should go on the IRIS for ECMFC certificates? The date the certification was issued or the date of last exam?

    Per the CMS published IRIS instructions, “Effective June 14, 2004, FMSGs are required to pass Step 1 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) for certification from the ECFMG. Do not use either the issuance date or the English examination date on the ECFMG certificate as the certification date. Instead use the latest examination date of any other examination as the certification date. For example, if the FMSG passed the CK test on May 15, 2004, and the CS test on July 1, 2004, then the certification date is the later date of July 1, 2004.”

  17. What is your process for determining if the hospital incurs all, or substantially all, of the costs for the training program in that setting?

    Normally, it’s the facility that pays for ~90% of the salaries, benefits and occasionally other subsidized costs. There must be a written agreement in place.

  18. Doesn’t Psych and Rehab have their own IME Cap that is not part of the 1996 caps?

    Yes. The cap is for the cost reporting period ended before 11/15/2004 for psych and rehab.

  19. For the Bonus Initial Residency, does it matter which residency specialty they switch from originally?

    Yes. The original residency specialty sets the Initial Residency Period (IRP) which cannot be changed (i.e., if the resident’s initial specialty was Internal Medicine their IRP is 3 years). If the resident subsequently switches to a specialty of Surgery, the resident’s IRP is still 3 years and will be weighted for the final 2 years of residency in their Surgery specialty.

  20. IME Calculation and Available Beds: Due to COVID and the economy, there is a nursing shortage that is affecting a hospital’s ability to staff beds. Would CMS be willing to consider changing from “available beds” to “staffed beds” during this CDC Public Health Emergency?

    Medicare is highly unlikely to use staffed beds due to the volume of decisions on the determination. But if you are not able to statutorily staff your “available” beds, are they truly “available” beds in your state? We would recommend using your bed count from the nursing units if possible. If not, only count beds in service up to your licensed beds. CMS does not view temporary COVID beds as “in service beds” and has instructed us to leave them out of the IME bed count for purposes of the Intern to bed ratio.

  21. How are the residency caps used in the IME and/or GME calculation?

    The FTE Caps limit the amount of reimbursement for IME and DME as an add on to DRG payments.

  22. FFY 2023 Inpatient PPS Proposed Rule. Currently, the proposed Rule is trying to address the GME “Penalty Cap” issue retroactive back to 2001. By the time 06/30 providers file FY 2022, the proposed rule will be final. If the hospital knows their prior two years are over the cap, can the hospital change the prior two years to the 1996 cap and get the full reimbursement amount and not 1/3 to avoid the 3-year rolling average?

    Since this is a proposed rule, we have no definitive comment. It appears that the proposed rule would only apply to cost reports that are inside the reopening window. Since the Proposed Rule states, it will apply the full FTE Cap to MCRs beginning on or after 10/1/2001, the facility may want to forecast its FTE CAP amount for FY 2022 by utilizing the same methodology. In other words, to make sure the facility did not fall under the cap for any given year we would set up modeling to show how the FTE Cap progresses through FY 2022 starting at the proposed FFY 2002 (10/1/2001). Make sure you protest any items on your FY 2022 As-Filed MCR you feel you may want to appeal (or that you may take an audit adjustment to) at a later date in case the provision is not finalized for some reason, or the MAC may be slightly behind in the calculation.

  23. Does the American Association of Colleges of Osteopathic Medicine and the American Osteopathic Association still approve new programs and positions as well?


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