GME/IME "All or Substantially All"

IMPORTANT ANNOUNCEMENT:

Hospital Submission of Medicare GME Affiliation Agreements During COVID-19 PHE Extended to January 1, 2022

Prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment for a Medicare discharge to reflect the higher patient care costs of teaching hospitals relative to non-teaching hospitals. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at 42 CFR §412.105.

Form

This spreadsheet is intended for use in determining the minimum payment that must be made from a hospital to a non-hospital setting to meet the "all or substantially all" requirement in order to claim interns and residents that train in non-hospital sites, pursuant to 42 CFR 413.75(b). The requirement is effective for cost reporting periods beginning on or after July 1, 2007. (Federal Register, May 11, 2007, Pgs 26948-26976)

The spreadsheet will accommodate most arrangements between a hospital and non-hospital site; however, it will not work in all possible situations.

A separate spreadsheet must be completed for each medical education training program in which interns and residents rotate to a non-hospital site. If a training program has rotations to more than one non-hospital site, a separate spreadsheet must be completed for each non-hospital site.

There are three sheets to this spreadsheet.

  • Sheet 1 identifies the training program at the non-hospital site and calculates the "all or substantially all" amount for the non-hospital setting. This sheet indicates whether the provider has met its requirements in paying all or substantially all the costs of training in the non-hospital site.
  • Sheet 2 accumulates resident rotations, by resident, and by rotation block.
  • Sheet 3 lists the physician compensation proxy amounts from the AMGA Physician Compensation Survey for 2006. With the exception of the annual update of the AMGA Physician Compensation Survey information, which is applicable to all providers, there is no input on Sheet 3.

Recommended Order of Completion: Although the spreadsheet will work properly regardless of the order of data input, we recommend the following order of completion. Enter the identifying information for the provider, the non-hospital site and the training program on Sheet 1. Then input the resident rotation information on Sheet 2 before returning to complete Sheet 1. The formulas on Sheet 1 will not compute properly until Sheet 2 is fully populated.

Documentation: The provider is responsible to maintain documentation to support the information on this spreadsheet. The provider should make the documentation available to the Medicare contractor upon request.

Sheet 1 Instructions

HEADER

Training Program Number (Input): Enter the number of the medical education training program. Enter only one program per spreadsheet.

Training Program Name (Input): Enter the name of the medical education training program. Enter only one program per spreadsheet.

Non-Hospital Site (Input): Enter the name of the non-hospital site. Enter only one non-hospital site per spreadsheet. If a training program has rotations to more than one non-hospital site, a separate spreadsheet must be completed for each non-hospital site.

Written Agreement/Concurrent Payment (Input): Indicate by checking the box whether the hospital has a written agreement with the non-hospital site or if it pays the non-hospital site concurrently. If there is a written agreement, the hospital should attach it to this document as support for the amounts paid to the non-hospital site.

A written agreement with the non-hospital site must be in place by the day before the rotation is scheduled to begin. The agreement must include the amount that represents the total cost of the training program at the non-hospital site, the amount that the hospital will incur (at least 90% of the total cost), the portion that reflects residents' salaries and benefits, and the portion that reflects teaching physician compensation. The amounts specified in the written agreement may be modified up to June 30 of the applicable academic year.

If the hospital actually pays all or substantially all of the costs "concurrently" while the training occurs in the non-hospital setting, a written agreement is not required. "Concurrently" means that the provider must liquidate the liability (training costs) by the end of the third month following the month in which the training occurred. The provider must be able to provide documentation to support the liquidation of these liabilities.

1. MEDICARE "ALL OR SUBSTANTIALLY ALL" TEST

A. Cost of Residents' Salaries and Fringe Benefits (Formula): This amount transfers from the total on Resident Direct Costs, line 2. It includes resident salaries, fringe benefits and applicable travel costs related to the rotation to the non-hospital site.

B. Cost of Teaching Physicians (Formula): This amount transfers from Teaching Physician Supervisory Costs, line 3J. It represents the supervisory teaching physician costs for the time that residents in this training program trained at the non-hospital site. This is computed using proxy or actual physician compensation, or a combination, based on the inputs selected for physician compensation.

C. Total Cost of Non-Hospital Site (Formula): This is the sum of the line 1A. Cost of Residents' Salaries and Fringe Benefits and line 1B. Cost of Teaching Physicians.

D. Minimum Cost Threshold (Formula): This is 90%. In order to meet the "All of substantially all" threshold, the hospital must pay the non-provider setting at least 90% of total costs of the rotation.

E. Required for "All or Substantially All" (Formula): This is line 1C. Total Cost of Non-Hospital Site multiplied by line 1D. Minimum Cost Threshold of 90%.

F. Minimum Teaching Physician Compensation (Formula): This is the greater of (line 1A. Cost of Residents' Salaries and Fringe Benefits less the amount on line 1E. Required for "All or Substantially All"), or 0. If the amount on this line is greater than 0, the hospital must make additional payments to the non-hospital site for supervisory teaching physician services.

G. Payments to Non-Hospital Site (Input): Enter any payments made by the hospital to the non-hospital site for supervisory teaching physician costs related to the training program. If this amount is greater than or equal to the Minimum Teaching Physician Compensation on line 1F, the "All or Substantially All" requirement has been met. If this amount is less than the Minimum Teaching Physician Compensation on line 1F, the "All or Substantially All" requirement has not been met.

Liquidation of Liability

If the "All or Substantially All" requirement is not met, the liability must be liquidated as follows:

  • If the provider has a written agreement with the non-hospital site, the liability must be liquidated within one year of the end of the cost reporting period, pursuant to 42 CFR 413.100..
  • If the provider pays on a concurrent basis (no written agreement), the liability for the costs of the training must be liquidated by the end of the third month following the month in which the training in the non-hospital site occurred, pursuant to 42 CFR 413.78(e) and (f).

2. RESIDENT DIRECT COSTS

For each resident rotating to the non-hospital site:

Column 1, FTE Count (Formula): The FTE count for the time the resident is training at the non-hospital site. This transfers from the resident FTE count on the Rotation Schedule on Sheet 2.

Column 2, Annual Stipend (Input): For each resident listed, enter the annual stipend paid by the hospital to the resident.

Column 3, Benefits Ratio (Input): If the hospital pays fringe benefits to the residents, enter the fringe benefit ratio based on the amount of fringe benefits compared to resident stipend. In most cases, this will be the same for all residents. Do not include malpractice costs.

Example: If the resident's salary is $50,000, and the resident fringe benefits are $10,000, the fringe benefit ratio is calculated at 20% (10,000/50,000).

Column 4, Travel/Lodging (Input): For each resident listed, enter the amount of travel and lodging expense, if any, related to each resident's rotation to the non-hospital site.

Column 5, Direct Costs (Formula): For each resident listed, multiply the FTE count by the sum of the annual stipend and the benefits ratio applied to the annual stipend. Add the travel and lodging expense.

Total (Formula): Compute the sum of Columns. Transfer the total for Column 5, Direct Costs, to line 1A. Medicare "All or Substantially All" Test, Cost of Residents' Salaries and Fringe Benefits.

3. TEACHING PHYSICIAN SUPERVISORY COSTS

A. Do any teaching physicians at this non-hospital site receive a salary or predetermined payment? Input Enter "Y" if yes, "N" if no.

B. AMGA Physician Compensation Survey – August 2006

Salary information, whether actual or proxy, must be entered for each teaching physician at the non-hospital site. For each physician acting as a supervisory teaching physician at the non-hospital site:

Column 1, Specialty (Input): From the pull-down menu, select the specialty of each teaching physician, not of the training program. If the specialty or a reasonable substitute is not available from the pull-down menu (dental), or if the actual salary will be used in lieu of the salary proxy, select "Other" or "Actual." Also, if the specialty is not listed, use the "less-specialized" form of that specialty. (i.e. "forensic pathology" uses "pathology")

If "other" is selected, specify the specialty. Proxy compensation cannot be used if "other" is selected, and actual compensation must be entered in column 3 for this physician.

Column 2, Proxy Compensation (Select Column 2 or Column 3, Pull-Down Menu): For each physician whose specialty was selected from the pull-down menu in Column 1, the proxy compensation amount from the AMGA Physician Compensation Survey related to that specialty will be transferred from Sheet 3 to column 2 for each line.

If actual physician compensation is being used for any or all the physicians, enter the actual compensation in column 3. This will override the proxy compensation in column 2. No proxy compensation will be shown in column 2 for any physician that has actual compensation shown in column 3.

Column 3, Actual Compensation (Select Column 2 or Column 3, Input): If the actual salary is being used in lieu of the proxy amount, enter the actual salary amount for each applicable line. No proxy compensation will be shown in column 2 for any physician that has actual compensation shown in column 3.

Column 4, Compensation Used for Comparison (Formula): For each line, the amounts entered in Columns 2 or 3 will be entered. This is the physician salary that will be used to determine the supervisory teaching compensation for the "all or substantially all" determination.

Column 5, Teaching Hours (per week) (Select Column 5 or Column 6, Formula): The spreadsheet will automatically use 3 hours per week in this column, unless an amount is entered in Column 6, Override Default Teaching Hours. If an amount is entered in Column 6, this will appear in Column 5.

Column 6, Override Default Teaching Hours (Select Column 5 or Column 6, Input): If actual hours are used in lieu of proxy hours, enter the number of hours per week each supervisory teaching physician spends teaching. If actual hours are used, these will replace the 3 hours automatically entered into column 5. A survey can be used if it covers at least two different, two-week periods.

C. Number of Teaching Physicians at Non-Hospital Site (Formula): This is the number of teaching physicians listed above in Column 4.

D. Average per Teaching Physician (Formula): This is the total Compensation Used for Comparison in column 4 divided by the Number of Teaching Physicians at the Non-Hospital Site on line 3C.

E. Prorated Average:

  • Training Days (Formula) are taken from Sheet 2, which determines the number of days in which residents rotated to the non-hospital site. These days are accumulated based the resident rotation schedules relating to that site.
  • % of Year (Formula) is determined by dividing the total days in the year (from Sheet 2) by the number of Training Days. This percentage is applied to the average teaching compensation.
  • Prorated Compensation (Formula) is determined by applying the % of Year to the Average per Teaching Physician Compensation on line 3D.

F. Resident to Teaching Physician Ratio "Limit" (Formula): There is a maximum ratio of one resident to one teaching physician. This is the lesser of the line 3C, Number of Teaching Physicians at the Non-Hospital Site, multiplied by the % of year on line 3E, or the total resident FTE count in line 2, column 2, FTE Count.

G. Estimated Physician Costs (Formula): The Average Teaching Physician salary on line 3D is multiplied by line 3F, Resident to Teaching Physician Ratio Limit to arrive at the estimated physician costs.

H. Non-Hospital Site Posted Hours of Operation (Input): Enter the number of hours (posted or advertised hours) per week the non-hospital site is open.

I. Teaching Ratio (teaching hours/hours of operation) (Formula): Divide the actual or proxy average teaching hours per week by the hours of operation for the non-hospital site. While this can be less than 7.5%, the ratio is capped at 7.5%.

J. Proxy for Teaching Physician Costs (Formula): Multiply the Estimated Physician Costs on line 3G by the Teaching Ratio on line 3I to arrive at the Proxy for Teaching Physician Costs. This amount is transferred to line 1B, Cost of Teaching Physicians.

Sheet 2 Instructions

This sheet is used to record the residents' rotations to the non-hospital site. Base on the input on this sheet, the residents and physicians FTE portions are calculated on Sheet 1.

This sheet is set up with up to 26 training blocks of time that are used to identify residents' rotations to the non-hospital setting. The rotation blocks can be tailored to meet the rotation blocks for the training at the non-hospital site.

FYB (Input): Enter the date of the beginning of the fiscal year.

FYE (Input): Enter the date of the end of the fiscal year.

Total days (Formula): This is the number of days in the fiscal year, as determined by the beginning and ending dates.

Block Columns (Input): Enter the beginning and ending dates for each rotation period. Rotation block dates can be tailored to reflect the rotations at the non-hospital site. More than one resident can be training in one rotation block.The number of days in the rotation block will be computed. Total days for all rotation blocks will be added together.

Residents (Input): For each resident, enter the percentage of time spent at the non-hospital setting in each training block, as applicable.

The rotation time for each resident is a percentage. The percentage must be determined based on the amount of time the resident is working during a given training block. Since each training program is different in terms of what makes up a full time resident, use of a percentage as opposed to entering the number of days worked was a more viable means to determine the resident FTEs.

Example 1: The training block is for a two-week period. Full time coverage for this training program is 5 days a week, 8 hours a day. The two-week period would therefore have 10 working days. The resident is assigned to the non-hospital site for six days during that training block. The percent would be 60%, or 6/10.

Example 2: The training block is for a two-week period. Full time coverage for this training program is 6 days a week, 8 hours a day. The two-week period would have 12 working days in it. The resident is assigned to the non-hospital site for six days during that training block. The percent would be 50%, or 6/12.

Days (Formula): The percentage of time for each resident in a rotation to the non-hospital site will be applied to the number of days in the rotation block and expressed as days in the Days column. Training days for each resident are accumulated in the last column. Total training days for all residents is added together and transferred to Sheet 1, line 3E, Prorated Average.

FTE (Formula): The FTE related to training in the non-hospital site for each resident is computed by dividing the number of training days for each resident by the number of total days in the fiscal year. The FTE amount for each resident is transferred to sheet 1, line 2, column 2, Resident Direct Costs.

Sheet 3 Instructions

This sheet has the physician salaries, by specialty, from the AMGA Physician Compensation Survey, August 2006. This is the source for the pull-down menu of physician specialties for Sheet 1, line 3. The survey used must be the data available as of the fiscal year beginning. (i.e. a FYB of 7/1/07 must use the 2006 AMGA because the 2007 is not published until August 2007), There is no geographic adjustment, nor can any other survey or data be used in it's place.

If the specialty is not listed, use the "less-specialized" form of that specialty. (i.e. "forensic pathology" uses "pathology")

The salaries will have to be updated annually for the year in question.

Affiliation agreements and any questions regarding affiliation agreements should be submitted to: GMEAffiliationAgreements@noridian.com

Last Updated Jun 26 , 2024