Whwn doing outside electives what takes away residency funding?

[toothless rufus]

I am trying to find out or if someone knows the details (or knows a good contact for the info) for what determines when doing an elective outside your hospital or affiliates will cause your residency not to receive funds for the resident during that elective? Thanks!

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[SouthernSurgeon]

I am trying to find out or if someone knows the details (or knows a good contact for the info) for what determines when doing an elective outside your hospital or affiliates will cause your residency not to receive funds for the resident during that elective? Thanks!

Complex question.

Short/general answer: residency slots are funded at the hospital level. Meaning your hospital gets the money from Medicare, and they disperse it to the residency programs.

So if you're not doing a rotation at the hospital (Ie away elective), the hospital has no incentive to fund you for that month since you're not providing any service to the hospital (and more specifically to the Medicare patient population at that hospital).

Programs/hospitals will enter into arrangements with other sites when they have a n established affiliate rotation there to exchange or maintain funding.

Also program get slots funded through the VA in exchange for doing rotations there.

 

[toothless rufus]

Complex question.

Short/general answer: residency slots are funded at the hospital level. Meaning your hospital gets the money from Medicare, and they disperse it to the residency programs.

So if you're not doing a rotation at the hospital (Ie away elective), the hospital has no incentive to fund you for that month since you're not providing any service to the hospital (and more specifically to the Medicare patient population at that hospital).

Programs/hospitals will enter into arrangements with other sites when they have a n established affiliate rotation there to exchange or maintain funding.

Also program get slots funded through the VA in exchange for doing rotations there.

My hospital is claiming that they will not receive funds for a resident during a rotation if we do it at another institution but per prior policy (Up until like two days ago when asked to clarify) was ok to do at a private physician office and they would still get paid.

They are not saying that they have the money already and won't pay us if we do that.

Does the hospital get paid from govt for residents in a lump sum at the beginning of year or are they paid per month per resident?
it
Who would even be policing if resident not at main institution and dock the funding?

 

[IMPD]

My hospital is claiming that they will not receive funds for a resident during a rotation if we do it at another institution but per prior policy (Up until like two days ago when asked to clarify) was ok to do at a private physician office and they would still get paid.

They are not saying that they have the money already and won't pay us if we do that.

Does the hospital get paid from govt for residents in a lump sum at the beginning of year or are they paid per month per resident?
it
Who would even be policing if resident not at main institution and dock the funding?

Arrangements can be made to claim Medicare funding for outside of the hospital training if specifically approved. as unique experiences that can't be claimed by another Medicare training site. Working at another site would be claimable by another hospital through Medicare and thus could result in double billing, which is one of the things that Medicare gets annoyed about.

Bottom line: We don't allow away rotations for this reason and places that do are forfeiting Medicare $$. For some programs, GME money is gravy and they make this sacrifice for the allure of the "away" rotation. For us, it is part of our lifeblood budget, so the answer is no.

 

[toothless rufus]

Arrangements can be made to claim Medicare funding for outside of the hospital training if specifically approved. as unique experiences that can't be claimed by another Medicare training site. Working at another site would be claimable by another hospital through Medicare and thus could result in double billing, which is one of the things that Medicare gets annoyed about.

Bottom line: We don't allow away rotations for this reason and places that do are forfeiting Medicare $$. For some programs, GME money is gravy and they make this sacrifice for the allure of the "away" rotation. For us, it is part of our lifeblood budget, so the answer is no.

Thanks. Makes sense. But what about if in a private office or institution? If they have some sort of per-rotation affiliation agreement or something?

 

[NotAProgDirector]

As others have already mentioned, it's VERY complicated.

In order for a rotation to be fundable by medicare, you need to be at your home institution or an affiliated site, and you must take care of some medicare patients.

1. What is "some medicare patients?" That's not entirely clear. My institution has said that as long as there is a single medicare patient, it's fine. But if you went and worked with a private doc who doesn't take medicare, then it's not fundable.

2. Who is in charge of enforcing these rules? It's the "Medicare Intermediaries" who are insurance companies that process claims for Medicare. There are several of them, so the rules for one part of the country may be different for another, and they can change the rules any time they want.

3. If a resident goes off site and it includes Medicare patients, is it billable? It can be if:
A. The place you go doesn't already bill for resident services under Medicare. i.e. if you go to a place that already has GME, then it's not billable.
B. The place needs to write a Letter of Affiliation contract with the GME office. This deliniates who is responsible for for paying the resident's salary, who will be allowed to bill Medicare, and other issues. It also MUST pay the supervising physician some amount of money for supervising the resident -- it can be a small amount. Many private offices either refuse to sign such contracts (worried that it's somehow going to create a problem for them), or GME offices are unwilling to manage all of the paperwork required for each private doc's office.

4. How do we actually get paid? We complete something called the Medicare Cost Report. I believe it gets submitted once per year. On it you must document exactly where each resident was for every day, and whether it's reimbursible or not. It is a HUGE pain. Most places have someone whose only job is to get this put together correctly. Remember that any errors can be considered Medicare fraud and can be punishable by $10K per error. If you never allow residents to go off site or have research time, it's easy.

5. Research is complicated. Lab research is never billable to Medicare. Clinical research if done with Medicare patients is probably OK. We still debate this. But research with a VA database is not. Lots of fun.

 

[PTPoeny]

Does anyone know how the rules are different for peds where there are no Medicare patients?

 

[SouthernSurgeon]

Does anyone know how the rules are different for peds where there are no Medicare patients?

Medicare is the primary source of GME funding (between Medicare and Medicaid CMS accounts for about 12 billion of the total 15 billion spent in GME funding), but not the only.

For peds there is a separate funding source for freestanding childrens' hospitals - the CHGME: (which incidentally just had a major budget cut)
http://bhpr.hrsa.gov/childrenshospitalgme/

 

[TheSportsMedDoc]

So I know this thread is a little older, but not entirely dead. And not too many have brought this topic up so I figured I'd ask... I'm in the same situation, cannot rotate away somewhere that has the training that I want to do for fellowship. One... unnamed, but somewhat prestigious institution has told me they would love to have me come by for 2, 4 or 6 weeks. They think they may be exempt from this rule, but possibly not, as they stated they receive $0 of GME funding.

Anyone know if that changes the scenario?

 

[NotAProgDirector]

Not much. If the place you are going does not have GME funding, then the away rotation is billable to your home institution if they write a contract with your away rotation site and pay them some amount of money (less than they get from Medicare) for your teaching costs. Whether both institutions will agree to do this is unknown. Without the agreement, then your time is non-reimbursable.

If the away location has GME funding, then it's worse. The away site can bill Medicare for GME reimbursement while you are there, but your home site remains responsible for your salary and benefits. It's completely up to the away site whether they want to pass back some of that money to your home site -- usually not.

 

[TheSportsMedDoc]

Not much. If the place you are going does not have GME funding, then the away rotation is billable to your home institution if they write a contract with your away rotation site and pay them some amount of money (less than they get from Medicare) for your teaching costs. Whether both institutions will agree to do this is unknown. Without the agreement, then your time is non-reimbursable.

If the away location has GME funding, then it's worse. The away site can bill Medicare for GME reimbursement while you are there, but your home site remains responsible for your salary and benefits. It's completely up to the away site whether they want to pass back some of that money to your home site -- usually not.

The away site receives no GME funding and says they would not be charging the institution. They're looking at it as an opportunity to have a closer look at me for when I apply. In this particular scenario. Would my home institution still receive the funding and not have to return it to the GME?

 

[IMPD]

The away site receives no GME funding and says they would not be charging the institution. They're looking at it as an opportunity to have a closer look at me for when I apply. In this particular scenario. Would my home institution still receive the funding and not have to return it to the GME?

As mentioned, your home institution needs to write a "PLA", basically a contract with the away in order to make this happen. That agreement is then usually approved at a high level committee so everyone knows about it. Although institutions have lots of agreements they are a bit of a PITA to write. Your PD will likely be able to tell you if they're willing to write it up.