Shadow Billing Compliance (IME/GME)
Hospitals are required to create “shadow claims” for Medicare when they treat patients enrolled in Medicare Advantage (MA) plans. These claims are required for a hospital to receive Indirect Medical Education (IME) / Graduate Medical Education (GME) reimbursement for these patients and also for HITECH compliance.
While all hospitals are required to comply, Shadow Billing is a significant issue for teaching hospitals, as Medicare’s methodology places the burden on the provider to identify A IME claims and to code the affected claims correctly before processing. Failing to capture eligible accounts negatively impacts IME revenue and ultimately affects the facility’s ability to reconcile and maximize GME through the cost report.
STINGRAY™, Healthcare Payment Specialists’s (HPS) proprietary software platform, helps hospitals manage the Shadow Billing process. HPS calculates eligible MA days for Shadow Billing and DSH. HPS differentiates itself by identifying patients that are MA eligible but were not identified as having that status at registration and tracking if shadow bills were not billed to final paid status.
- Identifies more recovery by identifying patients that are Medicare Advantage members but were not identified as being members at registration
- Supports HITECH Meaningful Use Compliance monitoring
- Connects with the Medicare Common Working File (CWF) across all Medicare regions and suffixes to identify members
- Connects with the Medicare Data Direct Entry (DDE) system to verify that a shadow bill claim has been billed and finalized
- HPS reviews claims 30 to 60 times faster than manual in-house processes
- Delivered as either a consulting service (with HPS performing the analysis), or as a SaaS solution with HPS implementing STINGRAY for use by the hospital to perform its own analysis
500+ Bed Teaching Facility — Recovered $2.3MM over 3-year period
Midwestern 500+bed teaching facility that handles more than 23,000 discharges per year and trains over 400 interns and residents per year.
Opportunity / Challenge
To compensate hospitals for costs associated with supervising and training health professionals, Medicare provides additional reimbursement for Indirect Medical Education and Direct Graduate Medical Education (IME/GME) based on a formula that factors in the severity of the number of Medicare accounts.
To receive this reimbursement, the hospital closely tracked accounts for all Medicare Part A and Part C (Medicare Advantage) patient stays. The internal reimbursement team was confident they had recovered the maximum IME payment for Medicare Part A claims, but suspected that some of the harder-to-find Medicare Advantage (MA) patient accounts had not been identified. These claims can be more difficult to locate among the thousands of patient accounts, particularly when certain patient information was missing or misreported. Billing and tracking payments for these accounts can also present a challenge and can lead to delayed reimbursement: these claims require a separate bill be submitted to Medicare Part A to receive the IME/GME reimbursement.
The reimbursement team wanted to ensure that every IME and GME dollar available to the hospital was gained before the timely filing deadline and chose HPS to review its accounts.
HPS has an aggressive process to identify eligibility segments and locate Health Insurance Claim numbers (HIC #) associated with MA patients as well as daily tracking the disposition of every claim until the hospital receives payment.
- HPS used proprietary in-house methods to identify Medicare Part C eligibility segments for every hospital patient. Even patient accounts that had already been billed were checked to ensure full reconciliation with HPS’s eligibility results. HPS’s process for identifying eligibility segments uses regressive analytics to ensure a high degree of accuracy and certainty in the results. Because the method is automated, we are able to review large amounts of data quickly. When it comes to reimbursement for graduate medical education costs, this speed is critical: if the GME claims are submitted before the PSR, the claims are paid at the time the hospital’s cost report is settled. If the claims are submitted after this time, the hospital may have to wait months or even year to realize this revenue.
- Using automated processes, we compared data sources to match and confirmed Medicare Advantage patient’s HIC #s when this information was either misreported or missing from a patient account.
- HPS tracked the status of claims on a daily basis. Our specialists reviewed any non-conforming claims to identify and resolve issues, which may have been delaying payment. These claims were tracked until the hospital received 100% of the entitlement amount due.
- HPS recovered $2.3 million of IME revenue over a 3-year period
“Over a nine month period reviewed, HPS found roughly 450 additional Part C claims which will add more than $100,000 to our hospital. They were able to use their automation to get this turned around in 3 weeks. I would definitely recommend working with HPS.” — Director Of Reimbursement, Midwestern Hospital