Post on 23-Aug-2014
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Medicare Indirect Medical Education (IME)How underpayments can occur at your hospital
What is Indirect Medical Education• 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.
Indirect Medical Education (IME) and
Medicare• Medicare pays teaching facilities for the
costs of medical education via Graduate Medical Education (GME) and Indirect Medical Education (IME) payments.
• GME covers the direct costs of a teaching program. Payments are made to the hospital via Medicare Cost Report settlements.
• IME covers the higher, soft costs of a teaching program and for FFS Medicare claims is paid as part of the overall claim reimbursement.
OVER 1,100 TEACHING HOSPITALS
RECEIVE IME PAYMENTS*
*Conference of Boston Teaching HospitalsIssue Brief - Medicare Indirect Medical Education (IME) Payments
Indirect Medical Education (IME) and
Medicare Advantage• Medicare Advantage claims are
submitted to the Medicare Advantage plan carrier for payment
• CMS requires that a separate “shadow bill” be sent to Medicare via the hospital’s MAC to receive IME payment and record utilization data
• IME payments will appear on the PS&R report as type 118
CLAIMS MUST BESUBMITTED WITHCONDITION CODES
04 AND 69
How Problems Can OccurMost hospitals have a good process in place to submit the IME shadow bills to CMS for patients registered under Medicare Advantage plans, however…
WHEN MEDICARE ADVANTAGE PATIENTS ARE NOT CORRECTLYIDENTIFIED AT REGISTRATION, A DISCONNECT IN THE BILLINGPROCESS MAY RESULT, AND THE SHADOW BILL IS NOT SUBMITTED.
How Problems Can Occur• Many hospital billing systems are setup to
automatically trigger a shadow bill when the patient is recognized as a Medicare Advantage patient at registration.
• When the Medicare Advantage plan is not recognized, the patient’s Medicare HIC may not be collected.
• The HIC number can often be difficult to track down later and the potential underpayments are significant.
THE MEDICARE HIC IS REQUIRED FOR
SUBMISSION OF THESHADOW BILL
Example IME claim issuePatient is a member of an Aetna Medicare HMO planPatient arrives at the hospital and is mistakenly registered under a different Aetna planShadow bill is not triggered in billing systemBill is sent to registered Aetna plan and is deniedMain claim is resubmitted manually to the correct Aetna Medicare HMO planShadow bill falls through the cracks
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Additional benefits of capturing Medicare utilization• Beyond the benefits of proper reimbursement,
correctly capturing Medicare utilization days have added benefits:
• Higher GME and Nursing Allied Health (NAHE) reimbursement at the time of Medicare cost report settlement
• Additional Medicare beneficiary days used in the DSH calculation for both teaching and non-teaching facilities
Timely Filing Issues• Unlike Transfer DRG
underpayments that only require a claim adjustment to correct underpayment, IME shadow bills were never filed and are subject to timely filing deadlines
• The timely filing limit for IME claims is 12 months
IDENTIFICATION OFMISSING IME SHADOW
BILLS SHOULD BE AREGULAR PART OF THE
REVENUE CYCLE
For more background on IME
• CMS.gov - Indirect Medical Education • American Association of Medical Colleges – Medicare IME explanation
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