Electives – A Common Adjustment in Medicare Audits
November 5, 2019
GME Solutions has over 20 years of experience working with Medicare auditors (i.e. Medicare Administrative Contractors, or MACs). The most common disallowances made by MACs concerning Graduate Medical Education (GME) payments result from resident elective rotations.
What are Elective Rotations?
Elective rotations provide an opportunity for residents to tailor their GME experience to meet their specific interests. For example, residents enrolled in a specialty program may use elective time to experience subspecialty rotations to assist with selecting a fellowship program. Other times, electives are used to pursue an academic pathway or research training program. International electives are offered by many programs and provide residents with a global perspective of healthcare. If elective rotations are valuable to GME Administrators and essential to the residents’ training, why are Medicare auditors frequently disallowing this time?
Medicare Graduate Medical Education Requirements
The following requirements need to be met for a hospital to receive Direct and Indirect Graduate Medical Education payments for a particular resident’s training rotation:
- The resident must be enrolled in a Medicare Approved Program
- The resident must be training at the hospital or a non-provider location
- The resident must be engaged in patient care or research that is associated with the treatment or diagnosis of a particular patient
As shown in the above criteria, unless specifically defined, elective rotations may or may not meet criteria two and/or three.
How to Avoid Audit Disallowances on Elective Rotations
Audits do not always happen promptly. Numerous hospitals nationwide are being audited for residents’ time completed over five years ago. Once the audit begins, knowledgeable program staff may no longer be available to answer the auditor’s questions regarding resident rotations. Even when program staff is available, they may not recall exactly the type of training or location of training of each resident’s elective rotation. If the hospital is not able to provide concrete evidence of the type of training or location of training, the rotation is certain to be disallowed by the auditor.
Timely documentation confirming the residents’ training information will prevent disallowance by the auditor. This documentation must be readily available by the finance office if requested by the auditor.