Increasing Audits of GME Hospitals
November 14, 2018
The Office of Inspector General (OIG) issued a report titled “CMS Did Not Always Ensure Hospitals Complied With Medicare Reimbursement Requirements For Graduate Medical Education”. Said report was based on OIG audits, which found that hospitals in six Medicare Administrative Contractors (MAC) jurisdictions counted residents (including interns) as more than one full-time equivalent (FTE) and, as a result, received excess Medicare graduate medical education (GME) reimbursement. This report summarizes the findings of those audits, providing information that may assist the Centers for Medicare & Medicaid Services (CMS) and MACs to achieve greater efficiency in the operation of Medicare.
The OIG performed eight audits that covered various periods between 2006 and 2013. For these audits, they obtained and reviewed data submitted by teaching hospitals in six selected MAC jurisdictions to determine whether or not hospitals claimed Medicare GME reimbursement in accordance with Federal Regulations.
The OIG identified in 7 of the 8 audits a total of 285 hospitals that claimed GME reimbursement for residents who were claimed by more than 1 hospital for the same period and whose total FTE count exceed 1 FTE, totaling $3,953,446 in excess Medicare GME reimbursement.
The overstated FTE counts and excess reimbursement occurred because CMS did not have adequate procedures to ensure that hospitals do not count residents as more than one FTE. For example, CMS did not review the IRIS data submitted by hospitals to detect whether a resident had overlapping rotational assignments (i.e. working at more than one hospital during the same period or required the MACs to perform this work).
The OIG recommended that CMS take steps to ensure that no resident is counted as more than one FTE. This includes implementing policies and procedures to analyze IRIS data or requiring MACs to determine if residents claimed by hospitals in their jurisdiction were claimed as more than one FTE. Because their audits covered only six MAC jurisdictions across various fiscal periods, they believe that, if CMS took steps to ensure that MAC jurisdictions implemented procedures, it could achieve significant cost savings.
In written comments on the report, CMS agreed with the OIG recommendations and stated that it has begun implementing what it described as a new national IRIS database that would help ensure that no resident is counted as more than one FTE. Previously, the data submitted by teaching hospital was housed at the Medicare contractor that oversaw the geographical jurisdiction of that teaching hospital. Since residents often rotate to teaching hospitals in multiple jurisdictions, Medicare contractors would not have access to some hospitals’ data. The new national database more easily allows identification of full-time equivalent residents counted in excess of one full-time equivalent because it can access data all Medicare contractor jurisdictions.
We are sure that this new system that CMS referred to in their response is the new XML-based IRIS (also known as STAR) that was discussed in the FY 2019 IPPS Final Rule. As indicated in the FY 2019 IPPS Final Rule, the system is not quite ready. GME Solutions has been participating in the IRIS Workgroup conducted by the company that has been tasked to develop the new system, CGI Federal, since April 2015.
How We Can Help
GME Solutions can complete a review of IRIS reports in order to ensure the weighted counts are reported accurately and the rotations in the Residency Management System are accurate for IRIS reporting purposes with a greater focus on those programs that have rotations at more than one hospital.
I have 32 years experience with the fiscal intermediary (FI), (now called MACs) including serving as Audit and Reimbursement Manager for the last 20 years with the FI. For the past 10 years, I have worked as a consultant for GME Solutions. Based on my experience with the FI and working with CMS I feel the MACs will now allocate more time to auditing GME providers.