Attachment_A1_-_SOW_Appendices.pdf

Revised: 5/31/2017 2:19 PM

APPENDIX A

Governing Federal Statues

Public Laws o Healthcare Research and Quality Act of 1999 (Public Law 106-129) https://www.gpo.gov/fdsys/pkg/PLAW-106publ129/pdf/PLAW-106publ129.pdf o The Children’s Health Act of 2000 (Public Law 106-310) https://www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf o Amendment to Section 340E of the Public Health Service Act (Public Law 108-490) ftp://ftp.hrsa.gov/bhpr/chgme/titlexx.pdf o Children’s Hospital GME support Reauthorization Act of 2006 (Public Law 109-307) https://www.congress.gov/109/plaws/publ307/PLAW-109publ307.pdfChildren’s o Hospital GME Support Reauthorization Act of 2013 (Public Law 113–98) https://www.gpo.gov/fdsys/pkg/PLAW-113publ98/pdf/PLAW-113publ98.pdf o The Teaching Health Center Graduate Medical Education Program, Section 340H of the Public

Health Service (PHS) Act, Section 5508 (Public Law 111–148) https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf o Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided additional funding for the THCGME Program (Public Law 114–10) https://www.congress.gov/114/plaws/publ10/PLAW-114publ10.pdf o Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Public Law 108-173) https://www.gpo.gov/fdsys/pkg/PLAW-108publ173/pdf/PLAW-108publ173.pdfSocial o Security Act, Section 1886 https://www.ssa.gov/OP_Home/ssact/title18/1886.htm

Code of Federal Regulations o CFR 412.105 https://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec412-

105.pdf ftp://ftp.hrsa.gov/bhpr/chgme/titlexx.pdf o CFR 413.65 https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-65.pdf o 42 CFR 413.75 – 42 CFR 413.83 (formerly 42 CFR 413.86)

413.75: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-

75.pdf

413.76: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-

76.pdf

413.77: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-

77.pdf

413.78: https://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec413-

78.pdf

413.79: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-

79.pdf

413.80 & 413.81: https://www.gpo.gov/fdsys/pkg/CFR-2002-title42-vol2/pdf/CFR-2002-title42-vol2-sec413-80.pdf

413.82: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec413-

82.pdf

413.83: https://www.gpo.gov/fdsys/granule/CFR-2010-title42-vol2/CFR-2010-title42-vol2-sec413-83 o CFR 415.152 https://www.gpo.gov/fdsys/pkg/CFR-2009-title42-vol3/pdf/CFR-2009-title42-vol3-sec415- 152.pdf

Federal Register Notices o 61 FR 46208 of August 30, 1996 https://www.gpo.gov/fdsys/pkg/FR-1996-08-30/pdf/96-22145.pdf o 63 FR 26318 of May 12, 1998 https://www.gpo.gov/fdsys/pkg/FR-1998-05-12/pdf/98-12231.pdf o 63 FR 26324 of October 1, 1998 https://www.gpo.gov/fdsys/pkg/FR-1998-10-01/html/98-26324.htm o 65 FR 37136 of June 13, 2000 https://www.gpo.gov/fdsys/pkg/FR-2000-06-13/pdf/00-14802.pdf o 65 FR 37985 of June 19, 2000 https://www.gpo.gov/fdsys/pkg/FR-2000-06-19/pdf/00-15332.pdf o 66 FR 12940 of March 1, 2001 https://www.gpo.gov/fdsys/pkg/FR-2001-03-01/pdf/01-5008.pdf o 66 FR 37980 of July 20, 2001 https://www.gpo.gov/fdsys/granule/FR-2001-07-20/01-18166 o 67 FR 60241 of September 25, 2002 https://www.gpo.gov/fdsys/pkg/FR-2002-09-25/pdf/02-24311.pdf o 67 FR 68879 of November 13, 2002 http://www.federalregister.com/Browse/AuxData/F63501C0-7E7D-403B-86C1-BE5189689664 o 68 FR 60396 of October 22, 2003 https://www.gpo.gov/fdsys/pkg/FR-2003-10-22/pdf/03-26626.pdf

APPENDIX B

Resident Full-Time Equivalent (FTE) Assessment Program Methodology Report

Children’s Hospitals Graduate Medical Education Payment Program (CHGME Payment Program)

Page Number

Section 1 Overview of the Children’s Hospital Graduate Medical Education (CHGME) Payment Program

• Overview 7-8

• Key Events in the CHGME Payment Program 8-9

• Interim Payment Determination and Disbursement

(Based Upon the Initial Application) 9-12

• Timeline for CHGME Payment Program 12

• Timeline of Key Events in the CHGME

Payment Program 12-13

Section 2 Executing the Resident FTE Assessment Program

• Background 17-18

• Guiding Principles 18

• Interfacing with CMS/Medicare Administrative

Contractors (MAC) 18-19

• Supporting Documentation – The CHGME Documentation

Guidance 19-20

• Responsible Hospital Official 20-21

• CHGME Fiscal Intermediary (CHGME FI) Responsibilities 21-22

• CHGME Regional Manager Responsibilities 22-24

• Timeframe for Resident FTE Assessment Program 24-26

• Determining which Resident FTE Counts to use for payment calculations 26-29

• Phases of the Resident FTE Assessment Program 29-32

• CHGME Payment Program Review and Approval of Final

Assessment Reports 32-35

• The Role of the CHGME Regional Manager 34-35

Section 3 Types of CHGME Payment Program Reviews

• Overview 39

• Desk Checks 40-46

• Desk Reviews 47-58

• Field Reviews

TABLE OF CONTENTS

Section 4 Direct Medical Education Review and Audit Issues

• CMS Form-2552-10 72

• Determining Whether an Individual is a Resident or a Physician – Policy Change 72-73

• Chief Resident 73

• Electronic Submission of Affiliation Agreements 74

• New Medical Residency Programs 74

• Clarification of Definition of New Medical

Residency Training Program 74-75

• Participation of New Teaching Hospitals in Medicare

GME Affiliation Groups 75 -76

• International Medical Graduates (IMGs) 77-78

• International Dental Graduates 78

• Non-Provider/Non-Hospital Settings 79

• Changes Relating to Payments to Hospitals for Graduate

Medical Education (GME) and Indirect Medical Education (IME) 79-80

• Section 5504 Provisions 80

Elimination of the “All or Substantially All the Cost at a Non-Provider Setting” Requirement and New Requirements for Hospitals

• Revision to Regulations to Allow More than One Hospital to Incur the Costs of Training Programs at Non-Provider Settings, Either Directly or Through a Third Party 80-81

• Changes to Regulations Regarding Recordkeeping and Comparison to Base Year 81-82 Counting Resident Time for Didactic and Scholarly Activities and Other Activities 82

• Definition of Non-Provider Setting That is Primarily Engaged in Furnishing Patient Care 83

• One Workday Rule 83

• Distinguishing Between Allowed Non-Patient Care

Activities and Non-Allowable Research Time 84

• Approved Leaves of Absence 84-85

• Regulations. for cost reporting periods beginning on or after July 1, 2007 85-88

• Hospital Complex 88-89

• Redistribution of Costs When Grants are Received –

Nonprovider Setting 89

Section 4 Direct Medical Education Review and Audit Issues (continued)

• Fraud and Abuse 89

• Duplicate FTE Residents 89-90

• Non-allowable FTE Residents 90

• Part-Time Status 90-91

• Weighting Factor for Initial Residency Period 91

• Various Sampling Options 91-93

• Sanctioned Residents 93

• Approval of Graduate Medical Education Programs 93-95

• Affiliation Groups/Affiliation Agreements 95

• Section 5503 of the ACA, “Revisions to the Reductions

And Increases to Hospitals’ FTE Caps for Graduate Medical Education Purposes 95-106

• Section 422 of the MMA, “Redistribution of Unused Residency Positions” 106-110

• DGME Initial Residency Period Limitations, Simultaneous Match 111

Section 5 Reopenings 112-114

Section 6 Procedures for Provider Reimbursement Review Board (PRRB) Appeals Process

• Background 115

• Request for a hearing and position statements 116

• Confidential Information 116

• Jurisdiction 117

• Withdrawing an Appeal 117

• Notice of hearing and parties to the hearing 117-118

• Presentation at the hearing 118

• Closing a hearing 118

• PRRB’s decision 118

• HRSA Administrator’s decision 119

Section 7 Internal Quality Control for CHGME FI Workpapers 120

Section 8 Monthly Progress Report and Conference Calls

• Assessment of Resident FTE Count Program Final Reports 121

• Conference calls 121-123

Section 9 CHGME FI Workplans 124

Section 10 Recent Developments 142

BLE O OF CONTENTS

CONTENTS

List of Figures

Figure 1 Timeline: CHGME Payment Program Key Events 14-15

Figure 2 Overview Decision Algorithm: Assessment of

Resident FTE Counts Initial Application Package 36

Figure 2.1 Overview Decision Algorithm: Assessment of Resident FTE Counts 37

Figure 2.2 Final approved Resident FTE Assessment Report

( HRSA-99-1) Communication Sequence FY 2013 38

Figure 3 Desk Check Process: Assessing Resident FTE

Counts for Medicare Cost Reports (MCRs) Settled by Medicare MACs 46

Figure 4 Desk Review Process: Assessing Resident FTE Counts for MCRs Not Settled by MACs and

Children’s Hospitals That File Low/No Utilization MCRs 58

Figure 5 Field Review Process: Assessing Resident FTE Count Discrepancies and Issues Unresolved During Desk Review Process 71

Exhibits Exhibits A-V

References Federal Register Issuances

List of Tables

A Increases/Decreases to 1996 FTE Resident Cap Due to Section 422 of the MMA

B DC Documentation Requests

C DR Documentation Requests

List of Appendixes

A Instructions to Complete Exhibits

B Open

Table of Contents - List of Figures and Exhibits

Overview

In 1999, Congress addressed the disparity of explicit graduate medical education (GME) funding between freestanding children’s teaching hospitals and other teaching hospitals by passing the Healthcare Research and Quality Act, which established the Children’s Hospitals Graduate Medical Education (CHGME Payment Program). The act was signed on December 6, 1999, and the legislation authorized the program for Federal fiscal year (FY) 2000 and FY 2001. On October 17, 2000, the Children’s Health Act of 2000 amended the Healthcare Research and Quality Act of 1999 extending the CHGME Payment Program through FY 2005. On December 23, 2004, additional amendments under Public Law 108-490 were made to Section 340E of the Public Health Service Act affecting the CHGME Payment Program. On October 6, 2006, Public Law 109-307 was passed extending the CHGME Payment Program from 2007 through 2011.

Currently, H.R. 297, ‘‘Children’s Hospital GME Support Reauthorization Act of 2013, Passed the House of Representatives on February 4, 2013, and moved to the Senate.

This bill extends the CHGME Payment Program from 2013 through 2017.

There are 54 freestanding children’s teaching hospitals across the country participating in the CHGME Payment Program. These children’s hospitals train about 30 percent of the nation’s pediatricians, nearly half of pediatric sub-specialists, and provide valuable training for physicians in many other specialties. Almost 50 percent of the patient care that children’s teaching hospitals provide is for low-income children, including those covered by Medicaid and those who are uninsured. More than 75 percent of inpatient care at children’s hospitals is devoted to children with one or more chronic conditions.

The CHGME Payment Program provides a more adequate level of support for GME training in U.S. children’s teaching hospitals that have a separate Medicare provider number. These hospitals receive relatively little funding from Medicare for GME.

Funding received by other teaching hospitals from Medicare exceeded $8.4 billion in

FY 2008.

In FY 2008, the CHGME Payment Program appropriated over $288 million, over $297 million in FY 2009, and over $317.5 million in FY 2010. An estimated $317.5 million was appropriated in FY 2011, an estimated $268 million in both FY 2012 and 2013, and the President’s proposal of $88 million in 2014. Since the inception of this program, the program has disbursed almost $3.0 billion in Federal GME support to freestanding children’s teaching hospitals.

GRADUATE MEDICAL EDUCATION PAYMENT

PROGRAM

The CHGME Payment Program is administered by the Graduate Medical Education Branch (GMEB) of the Division of Medicine and Dentistry (DMD), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS). The objective of the GMEB is to provide the assistance that freestanding children’s hospitals need to ensure a future pediatric workforce that will treat U.S. children.

For hospitals to be considered for CHGME Payment Program funding, they must comply with statutory eligibility requirements described in the application guidance and participate in the CHGME Payment Program’s application cycle, which consists of specific processes for any given FY.

Key Events in the CHGME Payment Program

Initial Application

The 2015 Initial Application for the Children’s Hospitals Graduate Medical Education (CHGME) Payment Program funds will be available with the release of the Funding Opportunity Announcement (FOA) on the Grants.gov website and must be received in the EHBs on or before August 1, 2014. The Funding Announcement Number hospitals need to “Find and Apply” for in Grants.gov is (TBD). This application process requires a two tier process: (Phase 1) applying in Grants.gov, due date July 14, 2014, 8:00 PM ET and (Phase 2) Completing the CHGME application through the use of the EHB, due date August 1, 2014, 5:00 PM ET.

For children’s hospitals, meeting all statutory and eligibility requirements, to receive CHGME Payment Program funding, they must submit a completed Initial application in accordance with the established deadlines..

Initial applications for CHGME Payment Program funding must include the following forms:

i. HRSA 99: Demographic and Contact Information

ii. HRSA 99-1: Determination of Weighted and Unweighted Resident FTE

Counts

iii. HRSA 99-2: Determination of Indirect Medical Education Data Related to the Teaching of Residents

iv. HRSA 99-3: Certification

v. HRSA 99-5: Application Checklist

Prior to the submission of a hospital’s initial application for CHGME Payment Program funding, documentation and supporting data related to resident FTE counts reported in a hospital’s CHGME Payment Program initial application must:

be collected (by the applicant children’s hospital);

certified by an responsible hospital official, including an official responsible for administering the residency programs; and be retained by the individual identified in HRSA 99, Section 5 of the hospital’s initial application. This individual should be able to forward any or all of information/data to the CHGME Payment Program or its representatives (e.g., CHGME fiscal intermediary (FI)) upon request.

Applications accepted for review must be completed following the CHGME Payment Program Application Guidance and instructions, available on-line at http://bhpr.hrsa.gov/childrenshospitalgme/index.html and include the above completed forms and supporting documentation as identified in the HRSA 99-5 (Application Checklist). The completed application package must be submitted via HRSA’s Electronic Handbook grant application system (EHB) by August 1, 2014. The HRSA forms that require a signature (HRSA 99 and HRSA 99-3) may be uploaded to the EHB as an attachment to the application (preferred method), sent by fax, or as an email attachment and must be submitted by August 1, 2014.

After the CHGME Payment Program receives and reviews all initial applications, copies of the CHGME Payment Program initial applications, specifically the HRSA 99 and HRSA-99-1 forms, as well as all required attachments, must be issued to the CONTRACTOR well before the October 1st start date. The CONTRACTOR will then distribute the initial application packages to the CHGME FIs to commence reviews. Prior to October 1, the children’s hospitals will furnish their IRIS and IRIS proxy diskettes to the CHGME FIs for sample selection purposes, if feasible.

The CHGME FIs will issue introduction letters (Exhibit F) to their respective providers outlining the type of review to be performed, as well as requesting preliminary supporting documentation.

In addition to submitting Exhibit F to the providers, the CHGME FIs will submit copies of Exhibit F to CONTRACTOR, the COR, as well as the respective HRSA regional managers. Any attachments containing PHI or PII information must be omitted.

Interim Payment Determination and Disbursement (Based Upon the Initial Application)

In accordance with CHGME Payment Program statutory requirements, information provided by participating children’s hospitals in their initial applications for CHGME Payment Program funding is used to calculate payments for all eligible children’s hospitals prior to the beginning of the FY (i.e., October 1st) for which children’s hospitals have applied for CHGME Payment Program funding. It is important to note that prior to the calculation of payments, data reflected in each application for CHGME Payment Program funding is validated to the extent possible by CHGME Payment Program staff.

Review of applications typically includes, but is not limited to:

(1) ensuring the children’s hospital completed its initial application for CHGME Payment Program funding in accordance with published Application Guidance and instructions;

(2) comparing data reported in the children’s hospital’s current (initial) application for funding to data reported by the children’s hospital and the CHGME FI in its previous application for CHGME Payment Program funding, where applicable (i.e., data reflected in the children’s hospital’s reconciliation application and the CHGME FI’s Resident FTE Assessment from the previous reconciliation cycle);

and

(3) identifying any areas, which require clarification or resolution either prior to the calculation of payments or during the Resident FTE Assessment process (e.g., resident FTE counts in hospital’s application do not match the MCR or the

CHGME FI’s Resident FTE Assessment Report from the previous cycle,calculation errors, etc.).

CHGME payments, allocated to eligible children’s hospitals, are a function of the number of resident FTEs participating in approved medical residency programs, inpatient discharges, case mix indexes, and the number of inpatient available beds. This data is reported by children’s hospitals in their initial applications for CHGME Payment Program funding. Payments are awarded for direct medical education (DME) and indirect medical education (IME) expenses, respectively. DME and IME payment calculations are subject to all rules, regulations, and policies governing the CHGME Payment Program.

On or after October 1st of the FY for which eligible children’s hospitals have applied for CHGME Payment Program funding, the CHGME Payment Program will begin making interim payments. CHGME Payment Program payments to eligible children’s hospitals will be contingent upon the passage of the Congressional appropriation of funds.

Children’s hospitals will be notified, in writing, of the Secretary’s interim payment determination. In accordance with CHGME Payment Program statutes, payments will reflect a 25 percent withholding from each interim payment for both DME and IME payments, as necessary, to ensure that a hospital will not be overpaid on an interim basis.

Assessment of Resident FTE Counts Reported in Initial Applications

The CHGME Payment Program statute, Public Law 109-307, mandates that “the Secretary (i.e., DHHS) shall determine any changes to the number of residents reported by a hospital in the (initial) application of the hospital for the current FY for both direct and indirect expense amounts.” Therefore, prior to the end of the FY (i.e., September 30th) for which children’s hospitals have applied for CHGME Payment Program funding, the Secretary must determine (reconcile) any changes to the number of resident FTEs reported by a hospital in its initial application for the current FY, which will impact final payments made by the CHGME Payment Program to all eligible children’s hospitals. This determination is done by conducting a comprehensive assessment of the resident FTE counts claimed by children’s hospitals in their initial applications for CHGME Payment Program funding which is described in detail in the following section.

Reconciliation Application

During the third quarter of each FY (typically April 1st) for which payments are being made, the CHGME Payment Program will release a reconciliation application for use by participating children’s hospitals to report changes in the resident FTE counts reported in their initial applications for CHGME Payment Program funding. For children’s hospitals to continue receiving CHGME Payment Program funding, they must submit a completed reconciliation application in accordance with established deadlines noted below. To be accepted by the CHGME Payment Program, the resident FTE counts reported by children’s hospitals in their reconciliation applications must be for the same Medicare cost report (MCR) periods identified in the hospital’s initial application for the subject FY and consistent with those reported by the CHGME FI in the FI’s most recent Resident FTE Assessment Report. The resident FTE counts from the most recent Resident FTE Assessment reports are used to determine the final amounts payable to children’s hospitals for the current FY for both DME and IME. Children’s hospitals whose resident FTE counts have not changed are not exempt from completing and submitting a CHGME Payment Program reconciliation application.

Reconciliation applications for CHGME Payment Program funding must include the following forms:

i. HRSA 99: Hospital Demographic and Contact Information

ii. HRSA 99-1: Determination of Weighted and Unweighted Resident FTE Counts

iii. HRSA 99-2: Determination of Indirect Medical Education Data Related to the Teaching of Residents

iv. HRSA 99-3: Hospital Certification

v. HRSA 99-4: Government Performance and Results Act Tables

vi. HRSA 99-5: Application Checklist

Applications accepted for review must be completed following the application guidance and instructions provided and include the above completed forms and supporting documentation as identified in the HRSA 99-5 (Application Checklist). The completed, signed application package must be submitted via HRSA’s EHB by May 1, 2015.

Children’s hospitals that were not eligible to participate or did not apply for funding during the initial application process for a given FY are not eligible to apply for and receive funding during the reconciliation application process for the same FY. These hospitals must wait until the next (initial) application cycle to apply for CHGME Payment Program funding.

Final Payment Determination and Disbursement (Based Upon the Reconciliation Application)

The Secretary will determine any balance due or any overpayment made to individual hospitals following the determination of changes, if any, to the number of resident FTEs reported by children’s hospitals in their reconciliation applications as a result of the Resident FTE Assessment Program. Children’s hospitals will be notified, in writing, of the Secretary’s final reconciliation payment determination during the fourth quarter (July 1st – September 30th) of the FY in which payments are being made. Payments made following the reconciliation application process will no longer reflect a 25 percent withholding from each payment for DME and IME. Reconciliation payments will also include any funds that are returned to the DHHS during a FY as a result of the recoupment of funds from a hospital or the termination of a hospital from the CHGME Payment Program.

Timeframe for Resident FTE Assessment Program

The assessment of resident FTE counts must occur within a six-month period of time to allow for reconciliation of payment within the appropriation year for which payments are made. Figure 1 provides the annual CHGME Payment Program timeline for the initial application, the assessment of FTEs resident counts, and the reconciliation application process. According to that timeline, the assessment of FTE resident counts for FY 2015 initial application will commence on October 1, 2014, and be completed no later than March 1, 2015.

Timeline of Key Events in the CHGME Payment Program (Figure 1.0)

The FY 2015 CHGME Payment Program Application Cycle timeline of events is as follows:

Initial Application and Payments*:

Application available (online): July 1, 2014 (provider’s only) Phase 1 applying in Grants.gov, due date July 14, 2014 Application deadline: August 1, 2014 (must be postmarked by this date) Interim Payments: Beginning on or about October 1, 2014

Resident FTE Assessment Process*:

October 1, 2014 through March 1, 2015

Reconciliation application and payments*:

Applications available (online): April 1, 2015 Application deadline: May 1, 2015 (must be submitted via HRSA’s

Electronic Handbook grant application system (EHB) by this date) Final (Adjusted) Payments: Beginning on or about July 2015

A more detailed timeline addressing various phases of the Resident FTE Assessment process are outlined in Figure 1.0.

Figure 1.0. Timeline: CHGME Payment Program Initial Application, Assessment of FTE Resident Counts, and Reconciliation Application

General Overview In order to assess compliance with the CHGME Payment Program requirements, an annual assessment of the children’s hospitals’ claimed FTE resident count(s) described would be assessed using the approach described in sections III-V.

Annual CHGME Payment Application / Assessment / Regulation Time Line for CHGME FIs:

Revised September 2013 14

FFY 2014 Federal Fiscal Year 2015 Task Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sept.

I. Hospital (FY)

• Academic June 30th

• Full Medicare Cost Report Dec.

31st

• Low/No Medicare Cost Report

Dec.

31st

• Initial Application Deadline

Aug. 1st

II. CONTRACTOR/CHGME FI

Assessment (FFY)

• Desk Check through January 21st

• Desk Review through January 21st

• Field Review through March 1st

• Progress Reports

(Monthly) Oct.

15th Nov.

14th

Dec.

16h

Jan.

15th

Feb.

14th

Mar. 14th Apr.

15th

• Conference Calls (Bi- Weekly after FRs Begin)

As needed

As needed

As needed

As needed

As needed

As needed

As needed

• Final Resident FTE Assessment Reports sent to hospitals and CHGME for Regional Manager Review

January 21, 2015 through March 1, 2015

• Resolution of Conflicts Finish – March

1st

III. CHGME Payment Program/HRSA (FFY)

• Initial Application Available on HAS to CHGME FIs

If available, initial applications will be posted to EHB/HAS during September 2013. If not, then October 1, 2013.

• Interim Payments October 1st through September 30th

• Review of Final Resident

FTE Assessment Reports by CHGME RMs

October 1, 2014, through March 15, 2015

Figure 1.0. Timeline: CHGME Payment Program Initial Application, Assessment of FTE Resident Counts, and Reconciliation Application

General Overview In order to assess compliance with the CHGME Payment Program requirements, an annual assessment of the children’s hospitals’ claimed FTE resident count(s) described would be assessed using the approach described in sections III-V.

Annual CHGME Payment Application / Assessment / Regulation Time Line for CHGME FIs:

Revised September 2013 15

FFY 2014 Federal Fiscal Year 2015 Task Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sept.

• Reconciliation Application

Available on HAS April 1st

• Reconciliation Payments June 1st

**Dates specified are based on no extensions granted and timeliness of HRSA-99 and HRSA-99-1 initial application distribution by HRSA

*Dates subject to change. Payment contingent upon availability of funds.

Revised September 2013 16

The following methodology is provided to detail the comprehensive effort and compliance that the CHGME FIs must use to perform the assessments of the resident FTE counts reported by all eligible children’s hospitals participating in the CHGME Payment Program.

Section 2 focuses on the background of the assessment of resident FTE counts, the CHGME FI responsibilities, supporting documentation, the identification of the responsible hospital official, and the final determination process.

Section 3 describes the three different types of CHGME Payment Program reviews and the processes involved in each review. Previous versions listed the review types in its own separate section.

Section 4 describes audit issues pertaining to direct medical graduate education and counting residents.

Section 5 addresses the “reopening of MCRs”. CMS has policies regarding the reopening of MCRs. The CHGME Payment Program has adopted this rule as part of the FTE resident counting rules. From CMS’ perspective, this policy is relevant only for those hospitals that file full MCRs. Children’s hospitals filing low- or no-utilization MCRs have the same option as the full filers, but do not have the administrative mechanism to implement the re-opening option.

Section 6 of this report focuses on the appeals process available through the CHGME Payment Program statute. It specifically discusses the role of the CHGME FI should any of the participating children’s hospitals appeal the final determination of the resident FTE counts being claimed on the respective CHGME Payment Program application.

Section 7 focuses on how CONTRACTOR ensures internal quality control for CHGME FI workpapers.

Section 8 describes the due dates and processes both CONTRACTOR as well as the

CHGME

FIs must follow when filing Monthly Progress Reports and conducting conference calls.

Section 9 describes the CHGME FIs workplans and the due dates to CONTRACTOR.

Section 10 includes information on recent legislative updates and revisions of CMS rules and regulations. In addition, information from past CHGME Payment Program and CONTRACTOR Alerts sent to CHGME FIs from CONTRACTOR and/or from the CHGME Payment Program is incorporated..

Revised September 2013 17

CHGME PAYMENT PROGRAM APPLICATION CYCLE

AND DEADLINES

Background

As previously indicated, CHGME Payment Program statute, Public Law 109-307, mandates that the Secretary determine (reconcile) any changes to the number of resident FTEs reported by a hospital in its initial application for the current FY, which will impact final payments made by the CHGME Payment Program to all eligible children’s hospitals. Children’s hospitals participating in the CHGME Payment Program file MCRs with the Centers for Medicare and Medicaid Services (CMS). About two-third of these hospitals file full MCRs (i.e., report residents to Medicare on Form CMS 2552-10, Worksheet E-4) and about one-third file low- or no-utilization MCRs (i.e., do not report residents on the Medicare cost report).

The CHGME Payment Program initially attempted to assess changes in resident FTE counts by collaborating with the CMS. On June 15, 2001, and January 28, 2002, CMS issued Program Memoranda (PM A-01-75 and PM AB-02-007, respectively) requesting that the Medicare Administrative Contractors (MAC) provide the CHGME Payment Program with resident FTE counts for children’s teaching hospitals. The MAC is the fiscal intermediary responsible for the receipt, processing and payment of Medicare fee-for-service claims for adult hospitals. In addition to providing core claims processing operations for both Part A and Part B and perform functions related to: Appeals, Provider Outreach and Education, Financial Management, Provider Enrollment, Reimbursement, Payment Safeguards, and Information Systems Security. This process did not prove adequate for CHGME Payment Program purposes, as it did not assess resident FTE counts for children’s teaching hospitals that file low- or no-utilization MCRs. In addition, MACs were unable to assess resident FTE counts, for CHGME Payment Program purposes, within the FY time constraints mandated by (CHGME Payment Program) law.

To address these challenges, the CHGME Payment Program contracted with the CONTRACTOR to develop a comprehensive process, using CHGME Payment Program-specific FIs, to assess resident FTE counts for all children’s hospitals participating in the CHGME Payment Program irrespective of the type of MCRs the hospitals’ filed. This process is known as the Resident FTE Assessment Program. Under contract, CONTRACTOR assigned a CHGME Payment Program-specific FI to each children's hospital (hereinafter, referred to as the CHGME FI) currently participating in and receiving funding from the CHGME Payment Program.

During December 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Under section 911 of the MMA, Congress requires that CMS replace the current fiscal intermediary (FI)

EXECUTING THE RESIDENT FTE ASSESSMENT

PROGRAM

Revised September 2013 18 and carrier contracts with competitively procured contracts that conform to the Federal Acquisition Regulation (FAR). Under the new Medicare Administrative Contractor (MAC) contracting authority, CMS has 6 years-between 2005 and 2011-to complete the transition of Medicare Fee-for-Service (FFS) claims processing activities from the FIs and carriers to the MACs. The provisions contained under section 911 are collectively referred to as Medicare Contracting Reform.

The CHGME Payment Program FTE resident assessment process introduces a new source of reviewed resident FTE counts that needs to be integrated with the following:

(1) CHGME Payment Program statutory requirements and published policy related to the acceptance of resident FTE counts;

(2) resident FTE counts generated by the MACs; and

(3) resident FTE counts resulting from an appeal to the Provider Reimbursement

Review Board (PRRB).

This Section provides an overview of key points guiding the assessment of resident FTE counts submitted by hospitals and outlines phases of the Resident FTE Assessment Program.

Guiding Principles

The Resident FTE Assessment Program is designed to assess resident FTE counts reported by all children’s hospitals in their Initial applications (e.g., Form HRSA 99-1) in an equitable fashion and within CHGME Payment Program time constraints. An assessment is performed regardless of the type of MCR the hospital has filed (e.g., full, low- or no-utilization). Children’s hospitals whose resident FTE counts have not changed are not exempt from completing and submitting a CHGME reconciliation application.

The Program is guided by CHGME Payment Program Regulations and CMS Regulations and involves three partners; CHGME Program Regional Managers, children’s hospitals receiving CHGME funds, and the CONTRACTOR/CHGME FIs.

Interfacing with CMS/Medicare Administrative Contractors (MACs)

The Resident FTE Assessment Program does not preclude or exempt children's hospitals or the CHGME FIs from communicating and working with their CMS/MACs as required under Medicare rules and regulations. To that end, the CHGME FIs are:

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• representatives (or agents) of the CHGME Payment Program, they do not replace the MACs for Medicare purposes.

• expected to use and build upon work previously conducted by CHGME and/or the MAC in prior years. The purpose is to minimize duplication of effort, control costs where appropriate, and minimize public burden.

• expected to communicate and work closely with their CMS counterparts, where appropriate, to obtain work papers, and to ensure that their findings are communicated to MACs for inclusion into the Medicare process, where appropriate.

• assigned to a children's hospital for CHGME Payment Program purposes may be different from the MAC assigned to the children's hospital for Medicare purposes.

Specifically, the CHGME FI may be from a different organization than that of the MAC or may be a different person within the same organization.

Supporting Documentation – The CHGME Documentation Guidance

The Resident FTE Assessment Program is an ongoing process as children’s hospitals continue to reflect data from more recently completed MCR periods in future CHGME Payment Program applications for funding. For this reason, the CHGME Payment Program strongly encourages CHGME FIs and hospitals to discuss documentation questions early in process of executing the annual Resident FTE Assessment Program.

A “Documentation Guidance” has been published by the CHGME Payment Program which is intended to assist participating hospitals in collecting and providing the documentation necessary for participating with the CHGME Payment Program. The Documentation Guidance also assists CHGME FIs with carrying out the Resident FTE Assessment Program. The Guidance is available on the HRSA website at:

http://bhpr.hrsa.gov/childrenshospitalgme/pdf/documentguidance.pdf

The level and type of supporting documentation requested by the CHGME FI must be, at a minimum, consistent with 42 CFR 413.75(d). Please note that recommendations and checklists provided in the Documentation Guidance are not exhaustive in nature, but represent the minimum documentation recommendations that will allow the CHGME FIs to accurately assess the resident FTE counts reported by an eligible children’s teaching hospital on its initial application.

http://bhpr.hrsa.gov/childrenshospitalgme/pdf/documentguidance.pdf

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The Documentation Guidance summarizes the following:

1. Current CHGME Payment Program requirements regarding hospital, residency program, and resident eligibility criteria;

2. Recommendations regarding required documentation that children’s teaching hospitals need to maintain related to those requirements;

3. An overview of CHGME Payment Program intern and resident data collection and recommendations for data submission;

4. Appendices to assist hospitals in developing agreements for aggregate caps (i.e., Medicare GME Affiliation Agreements) and non-provider/non-hospital settings; and

5. Checklists and other organizational tools that hospitals can use to more efficiently collect and submit documentation to the CHGME Payment Program or CHGME FI.

Note that documentation recommendations and checklists provided in the Documentation Guidance are not all inclusive. The recommendations represent the minimum documentation that will allow the CHGME FIs to accurately assess the resident FTEs reported by an eligible children’s teaching hospital on its initial application.

The CHGME Payment Program requires hospitals to discuss any documentation questions with their CHGME FIs (preferably prior to the beginning of the Resident FTE Assessment process). The Documentation Guidance also informs hospitals that CHGME FIs may request additional information or seek clarification from sources outside the Documentation Guidance or Methodology Report as needed to facilitate the Resident FTE Assessment process.

Responsible Hospital Official

Beginning in FY 2003, the CHGME Payment Program recommended to all participating children’s hospitals that documentation and supporting data related to resident FTE counts reported in a hospital’s application be collected and certified by an appropriate official of the hospital, including an official responsible for administering the residency programs.

The individual identified in Box 5 of the HRSA 99 form for the hospital’s CHGME Payment Program Initial application is designated as the individual who can provide the documentation in support of the information reported on the hospital’s application for CHGME funding. All inquiries and communications related to the Resident FTE Assessment Program will be directed to this individual. If the hospital

Revised September 2013 21 requests to have other hospital staff included in the CHGME FI correspondence, the CHGME FI will forward the request in an email to CONTRACTOR with a carbon copy to the COR and the CHGME Regional Manager. The hospital must be made aware and understand that the person identified in HRSA 99, Box 5 is the ultimate responsible hospital official for all requests and communications with the CHGME FI.

The hospital official is responsible for the following:

• Responding to all CHGME FI correspondence related to the Resident FTE Assessment Program process. All related correspondence should be addressed to this person.

• Maintaining the data submitted and ensuring the accuracy of data and all supporting documentation.

• Ensuring availability of all relevant information and/or data to the CHGME Payment Program and be able to forward information requested by the CHGME FI when it is requested.

CHGME Fiscal Intermediary (CHGME FI) Responsibilities

The CHGME FIs primary responsibility is to assess the resident FTE counts reflected in participating children’s hospitals initial applications (e.g., Form HRSA 99-1) for CHGME Payment Program funding. The CHGME FI determines any changes to the resident FTE counts initially reported within the FY time constraints mandated by law.

To execute the Resident FTE Assessment Program, the CHGME FIs issues Exhibit F to each of their respective children's hospitals. This exhibit introduces the CHGME FI to the hospital, as well as informing the children's hospitals of any supporting documentation that they may require in order to assess the resident FTE counts reflected in the hospitals’ applications. The level and type of supporting documentation requested must be consistent with 42 CFR 413.75(d). Documentation requirements are specified under 42 CFR 413.20ff, “Financial Data and Reports”, and 42 CFR 413.24ff, ‘Adequate Cost Data and Cost Finding.” Specific references to GME issues are under 413.75ff through 413.83ff.

The Resident FTE Assessment Program requires participating children’s hospitals to comply with requests from the CHGME FIs, within the time constraints provided, as any changes to resident FTE counts in one children’s hospital’s application for CHGME Payment Program funding affects the distribution of funds among all participating children’s hospitals. CHGME FIs are expected to use and build upon work previously conducted by CHGME and/or MAC in prior years. For this reason, the Resident FTE Assessment Program distinguishes between the two groups of children’s hospitals (i.e., those that report residents to Medicare and those that do

Revised September 2013 22 not) for purposes of minimizing duplication of efforts with respect to the assessment of FTE resident counts, controlling costs where appropriate, and minimizing public burden.

At the conclusion of the Resident FTE Assessment Program, the CHGME FIs will forward their final assessment reports to the respective children’s hospitals, CONTRACTOR, the MACs, and the CHGME Payment Program explaining the results of their review. The reports include CHGME FI-generated HRSA 99-1’s, which children’s hospitals must use to complete their reconciliation applications. The assessment reports may also include supporting documentation including, but not limited to: adjustment reports, updates to Medicare GME Affiliation Agreements, if applicable or available, updates to intern and resident database(s) (only to the respective children’s hospitals and the MACs), adjustments to CMS Form 2552-10 Worksheet E-4, or letters (to the MACs) requesting the reopening of one or more MCRs.

CHGME Regional Manager Responsibilities

At the heart of the CHGME Payment Program is the relationship between CHGME Regional Managers, CONTRACTOR, and the participating children’s hospitals. This relationship is fostered by ongoing one-to-one technical assistance to hospitals and organizations interested or currently participating in the CHGME Payment Program. To enhance the way technical assistance it provided the Program is divided into regions located throughout the United States and its territories. A CHGME Regional Manager (RM) is assigned to each region and is assigned to each hospital located within that region.

The responsibilities of the RM include:

1 Serving as the primary CHGME contact for those hospitals and organizations located in the region.

2 Providing hospital-specific, one-on-one technical assistance to the aforementioned parties as needed, requested, or required. The primary focus of technical assistance provided by RMs includes:

• Governing Rules and Regulations as they relate to hospital eligibility, full-time equivalent (FTE) counts, and payments.

• Assistance with and review of Initial Applications for CHGME funding.

• Assistance with and review of Reconciliation Applications for CHGME funding.

• FI/Hospital communications/negotiations, including CONTRACTOR involvement.

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3 Fostering the relationship between the CHGME Payment Program and participating hospitals on issues related to the Resident FTE Assessment Program and Medicare. This may include, but is not limited to,: hospital eligibility, application guidance and instruction, including the completion of forms, processing or auditing of application information, and communications with CONTRACTOR and the CHGME FIs as it relates to data reported by the hospitals in their CHGME initial and reconciliation applications for funding.

(NOTE: MCRs are the responsibility of the MAC. )

4 Facilitating the process by which hospitals apply for and receive CHGME funds to support the training of pediatric and other residents in GME programs.

The following methodology is provided to detail the comprehensive mechanism that CHGME FIs must use for the assessment of resident FTE counts for all eligible children’s hospitals participating in the CHGME Payment Program.

Timeframe for Resident FTE Assessment Program

To continue receiving CHGME funds, participating children’s hospitals must submit a completed reconciliation application in accordance with established guidelines and deadlines. Every year, typically on April 1st, the CHGME Payment Program makes available a reconciliation application for use by participating children’s hospitals to report changes in the resident FTE counts reported in their initial applications for CHGME funding within the same appropriation year. The assessment of resident FTE counts must occur within a six month period of time to allow for reconciliation of payments within the appropriation year for which payments are made.

Participating children’s hospitals are required to comply with requests from the CHGME FI within time constraints indicated. Likewise, every attempt must be made to resolve issues regarding resident FTE counts by the completion date of the Resident FTE Assessment Program.

Under certain circumstances, there may be a need to extend the date for completing the assessment. In these situations, the CHGME FI will send the request to CONTRACTOR, as well as identifying the specific reason(s) for the extension request. The CONTRACTOR will review the request and, if appropriate, will forward it to the COR for review and approval or no approval.

The COR’s response is communicated back to the CHGME FI through the CONTRACTOR. Requests for extensions are never made by the hospital to CONTRACTOR and never made directly to the COR or to the CHGME Regional Manager by the CHGME FI.

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The timeframe for the annual Resident FTE Assessment Program and the reconciliation application process is shown in Figure 1. Accordingly, the assessment of resident FTE counts for FY 2015 Initial applications will commence on October 1, 2014, and be completed with all issues resolved no later than March 1, 2015, unless these dates fall on a weekend, or an extension was granted by the COR. Then the due dates are on the next business day. Should the initial applications be issued by HRSA to the CONTRACTOR later than October 1, then an extension is warranted based on the number of days delayed. Desk Checks and Desk Reviews must be completed by January 21st and Field Reviews by March 1st, unless if these dates fall on a weekend, then the next business day.

Consideration of time constraints is important since the resident FTE counts from the final assessment reports are used to determine the final amount payable to children’s hospitals for both DME and IME.

Considerations with the MCR status when Assessing Resident FTE Counts

MCR Status Type

The CHGME Payment Program is statutorily tied to Section 1886 of the Social Security Act, and consequently, to all CMS-related and CHGME Payment Program specific rules and regulations, including published Federal Register Notices and Code of Federal Regulations, except where otherwise noted. Currently, all children’s hospitals participating in the CHGME Payment Program are required to report the number of resident FTEs trained based on the below rules and regulations and supporting documentation in the HRSA 99-1 form. The disclosure of this information allows for the determination of the “1996 Base Year Cap” and a three-year rolling average of resident FTEs counts for purposes of calculating CHGME Payment Program payments.

For hospitals that have not completed three (3) MCRs periods, special instructions are provided in the application guidance for determining resident FTE counts.

To complete a CHGME Payment Program application, hospitals must report resident FTE data as reflected in their:

1. most recently filed (or completed) MCR period for the period ending on or before December 31, 1996 (the “cap year");

2. most recently filed (or completed) MCR; and the

3. prior two Medicare cost reporting years.

The MCR status or code system provides a mechanism for identifying that “point on time” as it relates to the resident FTE counts being reported and is based on whether or not the resident FTE count for a particular MCR period has been previously audited and/or finalized/settled by a CHGME or MAC. The guiding principle behind this coding system is to tell the story of what has transpired related to the resident FTE count being

Revised September 2013 25 reported for a particular MCR reporting period (i.e., what, if any, and the level of, audit or assessment work that has been conducted on a particular MCR period) to ensure that the best resident FTE count data available for (that) MCR period is used to calculate CHGME Payment Program payments while maintaining compliance with governing statutes, rules, and regulations. The “hierarchy” is divided into two categories to address separately resident FTE data for hospitals that filed full MCRs and hospitals that filed low- or no-utilization MCRs. Please note the progression that follows (in the “life” of the MCR) in the codes and related definitions.

Hospitals that file full MCRs: the MCRs must be filed and accepted by the MAC prior to the CHGME Payment Program Initial application deadline in order to be considered and reflected in the HRSA 99-1.

Hospitals…