How Medicare Indirect Medical Education (IME) Underpayments Occur

of 11 /11
Medicare Indirect Medical Education (IME) How underpayments can occur at your hospital

description

Learn about common problems associated with reimbursement for Medicare Indirect Medical Education (IME) and how your hospital can avoid underpayment situations. Slides include background information on Indirect Medical Education (IME), examples of how reimbursement issues can occur, and additional learning resources.

Transcript of How Medicare Indirect Medical Education (IME) Underpayments Occur

Page 1: How Medicare Indirect Medical Education (IME) Underpayments Occur

Medicare Indirect Medical Education (IME)How underpayments can occur at your hospital

Page 2: How Medicare Indirect Medical Education (IME) Underpayments Occur

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.

Page 3: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

Page 4: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

Page 5: How Medicare Indirect Medical Education (IME) Underpayments Occur

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.

Page 6: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

Page 7: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

1

2

3

4

5

6

Page 8: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

Page 9: How Medicare Indirect Medical Education (IME) Underpayments Occur

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

Page 10: How Medicare Indirect Medical Education (IME) Underpayments Occur

For more background on IME

• CMS.gov - Indirect Medical Education • American Association of Medical Colleges – Medicare IME explanation

Page 11: How Medicare Indirect Medical Education (IME) Underpayments Occur

For timely updates related to Medicare, hospitals, and healthcare payment trends, subscribe to our blog

BESLER Consulting609.514.1400877.4BESLER

[email protected]

3 Independence WaySuite 201

Princeton, New Jersey 08540