Most hospitals have a good process in place to submit Medicare Indirect Medical Education (IME) shadow bills to CMS for patients registered under Medicare Advantage plans, but issues can still occur resulting in underpayment.
Teaching hospitals receive a payment from Medicare for Indirect Medical Education (IME) and Graduate Medical Education (GME) expenses. This payment helps to defray the added costs of maintaining teaching programs. For traditional Medicare patients, the IME payment is automatically paid by Medicare when a claim is processed.
For most Medicare Advantage claims, however, a separate request to Medicare must be made to receive the IME payment. Hospitals make this IME payment request by submitting a “shadow bill.” GME payments are determined at cost report settlement, and are impacted by the number of Medicare Advantage days reported.
Over the years, many providers have developed a reliable process to ensure that Medicare Advantage shadow bills are submitted properly. In some situations, however, Medicare Advantage patients may not be correctly identified at the time of registration.
Only after a denial is received is the Medicare Advantage eligibility determined. In these cases, the normal shadow billing process may not occur when the claim is rebilled, and the hospital will not receive the added IME and GME reimbursement to which it is entitled.
A practical example could look something like this:
- Patient is a member of an Aetna Medicare HMO plan
- Patient arrives at the hospital and is mistakenly registered under a different Aetna plan
- Shadow bill is not triggered in billing system
- Bill is sent to registered Aetna plan and is denied
- Main claim is resubmitted manually to the correct Aetna Medicare HMO plan
- Shadow bill falls through the cracks
To continue reading about how to avoid Medicare Indirect Medical Education (IME) underpayments, click through the slides below and visit Slideshare to download or share them.
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