Looking for more information about IME & GME Revenue Recovery Strategies? BESLER’s Director of Revenue Integrity Services Olga Barone-Allan answers your questions from the recent webinar.
To watch Olga’s IME & GME Revenue Recovery Strategies Webinar, click HERE.
- What additional days would children’s hospitals be able to account for? Are the additional days a percentage of just Medicare claims?
Children’s hospitals would be able to count all the days that have IME claims submitted to Medicare and paid. These shadow claim days are counted on your PSR report provided they are submitted and paid. These days would be counted as Medicare Advantage days.
- Does shadow billing also apply to Medicaid fee for service?
No, it does not apply to Medicaid fee for service.
- Does this education today apply to a Critical Access Hospitals?
From the Medicare Claim Processing Manual – 200.2 – Submission of Informational Only Bills for Maryland Waiver Hospitals and Critical Access Hospitals (CAHs)
(Rev. 2066, Issued: 10-15-10, Effective: 10-01-10, Implementation: 01-03-11)
Acute care hospitals already submit informational only bills for purposes of including Part C days in the Disproportionate Share (DSH) calculations, as explained in Section 20.3 above. However, Maryland waiver hospitals and CAHs do not currently submit informational only bills. In order for CMS to capture Part C days for purposes of calculating EHR payments, Maryland waiver hospitals and CAHs must submit informational only claims to Medicare, effective for discharges October 1, 2010. Informational only claims are claims billed for patients enrolled in a Medicare Advantage (MA) Plan and contain a condition the following elements:
• Covered 11X TOB (not 110)
• Condition Code 04
• Medicare is the primary payer
• There is no MSP
• Beneficiary‘s Medicare HICN
• All other required claim elements - How does CMS and the MACs determine which hospital is a teaching hospital? Do they look to see if revenue on E, A and E-4? We have a hospital that was determined to not be a teaching hospital despite having residents rotating into their hospital. But they did not record any revenue on E, A or E-4 as they did not have a cap or GME affiliation agreement.
Centers for Medicare and Medicaid Services (CMS) designates hospitals as teaching hospitals if they submitted Open Payments to CMS for Medicare direct graduate medical education (GME), IPPS indirect medical education (IME), or psychiatric hospital IME programs during the last calendar year.
- How does CMS determine whether a hospital is a teaching hospital or not? For example, if a hospital has current year FTE’s reported subject to the cap but has no cap, they won’t report IME/GME revenue on E, A/E-4. So, in this case, are they not considered a teaching hospital?
Centers for Medicare and Medicaid Services (CMS) designates hospitals as teaching hospitals if they submitted Open Payments to CMS for Medicare direct graduate medical education (GME), IPPS indirect medical education (IME), or psychiatric hospital IME programs during the last calendar year.
- Does BESLER also audit for NYS IME?
Yes, as long as you are a teaching hospital.
- Should the shadow bills be sent out for Managed Medicare patients as well?
The shadow claims are sent to Medicare for Managed Medicare only.
- Does the remittance advice break out the portion of the payment that specifically relates to IME?
Based on the condition code on the remit, the IME is a separate remit. It’s not mixed in with the inpatients in terms of line items, but if you look at the last page of the claim in DDE, you will see it.
- Did you say Psych GME claims are a 111 with 04 even if teaching?
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. Consistent with the regulations at 42 CFR 412.106(b)(2)(i) and 412.106(b)(2)(iii), patients who are enrolled in Medicare Advantage (administered through Medicare Part C) should also be included in the Medicare fraction. These days will be included in the Medicare/SSI fraction, but in order for them to be counted, the hospital must submit an informational only bill (TOB 111), which includes both Condition Code 04 and the CMG code from the IRF PAI, to their Medicare contractor. This will ensure that these days are included in the IRF’s SSI ratio for Fiscal Year 2007 and beyond.
Teaching IRFs do not have to submit an additional bill with Condition Code 04. They already submit bills with Condition Codes 04 and 69 for Indirect Medical Education payments and CMS will use the information from these bills for the SSI ratio. IRFs that received LIP payments during FY 2006 are also required to submit informational only bills for their Medicare Advantage patients. Informational Only Claim Elements:
– Covered 111 TOB
– Condition Code 04
– Medicare Fee-for-Service is the primary payer
– There is no MSP
– Beneficiary’s Medicare HICN
For claims prior to October 1, 2011, report the Revenue Code 0024 line containing CMG A9999 and, instead of inputting the transmission date of the IRF-PAI in the service date field (as is required for FFS claims), input the discharge date as a default for these informational only claims. The discharge date is required on informational only claims to reduce reporting burden for IRFs who may be submitting “old” informational only claims. - Are Shadow or IME claims required when the Medicare Advantage is secondary to a group insurance which would make the IME and Shadow claim secondary?
Shadow claims are only when the managed Medicare is primary.
- Can you bill IME for a secondary MA plan?
Shadow claims are only when the managed Medicare is primary.
- On inpatient downgraded to Observation, can you still bill IME?
No, because Observation is considered outpatient.
- Can you bill IME if the inpatient claim is downgraded to observation?
No, because Observation is considered outpatient.
Related Resources
- WEBINAR: IME & GME Revenue Recovery Strategies Webinar (recording and slides)
- IME & GME Revenue Recovery Strategies Webinar [PODCAST]
