1. CHGME Payment Program Resident FTE Assessment Program and Documentation Guidance U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions Division of Medicine and Dentistry Graduate Medical Education Branch

2. The CHGME Payment Program Partners CHGME Payment Program Staff Participating Children’s Hospitals CHGME Fiscal Intermediaries CMS Regulations CHGME Payment Program Regulations

3. Accuracy, Availability and Certification of Supporting Documentation

4. Application Certification Form HRSA 99-3

5. Certifying Official Certifying Official: A Certifying Official is the individual selected and empowered by the applicant hospital to certify the legitimacy of the application for funds under the Children’s Hospitals Graduate Medical Education (CHGME) Payment Program.

6. Certification Statement I certify that I have examined the accompanying electronically or manually filed CHGME Payment Program application and that, to the best of my knowledge and belief, all information on the Fiscal Year (insert fiscal year) application provided by (insert Hospital Name) is true, correct and complete and meets the requirements of 42 U.S.C. 256e, and applicable laws, regulations and policies.

7. Certification Statement (continued) If I become aware that any information in this form is not true, accurate, or complete, I agree to notify the CHGME Payment Program of this fact within 30 days. (Note: Any changes in the information reported in this application must be reported to the CHGME Payment Program within 30 days of said change.)

8. Certification Statement (continued) I understand that any omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to the CHGME Payment Program may be punishable by criminal, civil, or other administrative actions including fines, penalties, and/or imprisonment under Federal law.

9. I acknowledge that any funds paid to (Hospital Name) in excess of the amount to which the hospital is determined to be entitled under the terms and conditions of the award are subject to recovery or offset by Health and Human Services (HHS) pursuant to the Federal Claims Collection Act and implementing regulations and 45 CFR Part 30. Certification Statement (Continued)

10. What does the law require the Secretary of HHS to do?

11. Statutory Mandate Public Law 106-310 mandates that the Secretary “determine any changes to the number of residents reported by a hospital in the (initial) application of the hospital for the current fiscal year for both direct expense and indirect expense amounts.”

12. FY 2010 Application Cycle Initial application and payments (1) :  Application forms available: July 1, 2009  Application deadline: August 1, 2009  Payments: Beginning on or about October, 2009 (2) : Resident FTE Assessment Process (1) :  October 1, 2009 through March 1, 2010 Reconciliation application and payments (1) :  Application forms available: April 1, 2010  Application deadline: May 1, 2010  Payments: Beginning on or about July 2010 (3) 1. Dates are subject to change. 2. Payments contingent upon availability of funds. 3. These payments are adjusted based upon the Resident FTE Assessment process and the reconciliation applications.

13. Resident FTE Assessment Program Participating children’s hospitals are required to comply with requests for supporting documentation from the CHGME FIs, within the time constraints provided. Any changes to resident FTE counts in one children’s hospital’s application affects the distribution of dollars among all eligible children’s hospitals. CHGME FIs use and build upon work previously conducted by CHGME and/or Medicare FIs in prior years.

14. Documentation in Support of Resident FTEs Claimed in a Hospital’s Application for CHGME Payment Program Funding

15. Hospitals Eligibility Criteria and Supporting Documentation

16. Residency Programs Eligibility Criteria and Supporting Documentation

17. Residents Eligibility Criteria and Supporting Documentation

18. Compliance Requirements of 42 CFR 413.75(d) To include a resident in an FTE count for a particular cost reporting period, the hospital contact identified in section 5 of the HRSA 99 should possess and retain the following information (for each resident):

19. 42 CFR 413.75(d) in detail… 1)the name and social security number of the resident (fellow); 2)the type of residency program in which the individual participates and the number of years the resident has completed in all types of residency programs;

20. 42 CFR 413.75(d) in detail… 3)the dates the resident is assigned to the hospital and any hospital-based providers; 4)the dates the resident is assigned to other hospitals, or other freestanding providers, and any non-provider setting during the cost reporting period, if any;

21. 42 CFR 413.75(d) in detail… 5)the name of the medical, osteopathic, dental, or podiatric school from which the resident graduated and the date of graduation; 6)the name of the employer paying the residents salary;

22. 42 CFR 413.75(d) in detail… 7)if the resident is a foreign medical graduate (FMG) or an international medical graduate (IMG), documentation concerning whether the resident has satisfied the requirements of paragraph (a) of 413.80.

23. Resident Counts Resident counts are based on the number of residents training at the hospital complex and certain non-hospital/non-provider settings/sites throughout the hospital’s fiscal year. Residents are counted as FTEs based on the total time necessary to fill a full-time residency slots for the year. 42 CFR 413.78

24. Resident FTEs A resident FTE is measured in terms of time worked during a residency training year. It is not a measure of individual residents who are working.  If a full-time resident spends all time that is part of the approved training program in the hospital complex or qualified non-hospital site, the resident is counted as 1.0 FTE.  No resident may count as more than 1.0 FTE. 42 CFR 413.78

25. Partial Resident FTEs A partial FTE resident is a resident who does not spend all time that is part of the approved training program in the hospital complex or qualified non- provider (non-hospital) setting. 42 CFR 413.78

26. When would a resident be counted as a Partial FTE? A resident will count as a partial FTE based on the proportion of time worked at the children’s hospital and qualified non- provider settings relative to the total time worked in a full- time residency slot if the resident:  is part-time;  rotates to other hospitals as part of the approved training program sponsored by the children’s hospital;  is in a program sponsored by another hospital and spends one or more rotations at the children's hospital;  is on maternity leave;  joins or leaves a program mid-year; or  passes the USMLE mid-year.

27. Weighting Resident FTEs Residents are divided into two categories, those in their: a.initial residency period; or b.beyond their initial residency period

28. Initial Residency Period (IRP) For allopathic residency programs:  the minimum number of years of formal training required for initial board eligibility in a specialty as specified in the current Directory of Residency Training Programs. For osteopathy, dentistry, and podiatry programs:  the minimum number of years of formal training necessary to satisfy the requirements of the approving body for those programs. 42 CFR 413(a)

29. Beyond the Initial Residency Period Residents who are beyond their IRP, are weighted by a factor of 0.5 (or ½). 42 CFR 413.79(b)

30. Where are residents counted? Residents are counted in: a.the hospital complex; and in b.non- provider (non-hospital) settings

31. Hospital Complex The time a resident spends anywhere within the hospital complex may be included in the resident FTE count for CHGME Payment Program purposes. 42 CFR 413.78(a)

32. Non-Provider Settings The time residents spend in non-provider (or non- hospital) settings such as freestanding clinics, nursing homes, and physicians’ offices in connection with approved programs may be included in determining the number of FTE residents in the calculation of a hospital’s resident count if certain conditions are met. 42 CFR 413.78

33. Availability and Certification of Supporting Documentation

34. Availability of Supporting Documentation Documentation must be readily available and retained by the individual identified in HRSA 99, Section 5, of the initial application forwarded to the CHGME Payment Program or the CHGME FI for consideration. This individual should be able to forward the information to the CHGME Payment Program or CHGME FI upon request.

35. Accuracy of Resident Counts  Hospitals are responsible for the accuracy of the resident counts submitted to HRSA and are subject to audit.  Hospitals are not required to submit documentation to support resident counts reported on their CHGME Payment Program application. However, hospitals should be prepared to produce documentation in accordance with 413.75(d) in any subsequent audit carried out by the Department. Hospitals that do not report FTE resident counts to Medicare are not exempt from this policy.

36. Certification of Supporting Documentation The information (documentation in support of residents included in the FTE count for a particular cost reporting period) must be certified by an official of the hospital and, if different, an official responsible for administering the residency program. 42 CFR 413.75(d)

37. Goals and Objectives of the CHGME Payment Program Resident FTE Assessment Program

38. Resident FTE Assessment Process  In accordance with the contractual requirements, BCBSA assigns a CHGME FI to each children’s hospital currently receiving CHGME Payment Program funding.  The CHGME FI conducts an assessment of resident FTE counts reported by the children's hospital in its initial application (HRSA 99-1) for CHGME Payment Program funding to determine any changes to those resident FTE counts prior to the CHGME Payment Program reconciliation application cycle.

39. Resident FTE Assessment Process, continued.  The CHGME FI follows a detailed protocol based on CMS rules and regulations designed to ensure that each resident FTE claimed by the children’s hospital is documented in accordance with 42 CFR 413.75(d). There is 100 percent assessments (no sampling) of dental residents.

40. Resident FTE Assessment Process, continued.  The CHGME FI adjusts, where required, resident FTE counts not documented in accordance with 42 CFR 413.75(d).  The CHGME FI and children’s hospital work together to resolve discrepancies.

41. Overview of FTE Assessment Process (Continued)  The CHGME FI reports his/her findings to the children’s hospital, the CHGME Payment Program, and the Medicare FI in a Final Resident FTE Assessment Report.  The children’s hospital uses the CHGME FI Final Resident FTE Assessment Report to complete its reconciliation application for CHGME Payment Program funding.

42. Overview of FTE Assessment Process, continued.  The CHGME Payment Program recalculates payments for all children’s hospitals based on all CHGME FI Final Resident FTE Assessment Reports.

43. Resident FTE Assessment Program – Levels of Review 1.Desk Check 2.Desk Review 3.Field Review The level of review depends primarily on whether a review has been previously conducted by CMS or CHGME.

44. 1.Desk Check (DC) An assessment of Intern and Resident FTE counts is done on :  full MCRs that have been settled by the Medicare FI and are not in the process of being reopened; or  low- or no-utilization MCRs that have previously been assessed by the CHGME FI. The assessment consists of comparing FTE resident counts in the most recent CHGME Payment Program application (HRSA 99-1) to:  those in the settled MCR, or  the CHGME FI’s final resident assessment report from the previous application cycle.

45. Desk Check Flowchart

46. 2.Desk Review (DR) An assessment of Intern and Resident FTE counts is done on MCRs that are/were:  open (not settled);  currently reopened; or  filed as low or no utilization MCR with the Medicare FI and have not been assessed by the CHGME FI in previous years. A DR may also be done with a DC when the DC has unresolved variances after reviewing all supporting documentation. The review consists of verifying the FTE resident counts in the CHGME Payment Program initial application (HRSA 99-1) through established assessment procedures.

47. 3.Field Review (FR) An assessment is done on Intern and Resident FTE counts at the hospital site. It focuses primarily on DRs with issues that could not be resolved at the DR.

48. Field Review Triggers Items that could trigger a FR include, but are not limited to:  An overwhelming amount of documentation would have to be submitted to adequately satisfy area under review  Issues could not be adequately cleared during the DR  A reopening was conducted and the revisions do not appear reasonable and cannot be resolved in a DR  Unexplained changes in the number of FTEs  Change in Affiliation Agreements  Changes in hospital ownership  Unexplained inconsistencies with the resident information  Geographic proximity of CHGME FI to hospital.

49. Re-openings For full-filers: After completion of DC, DR, and/or FR the CHGME FI or the Hospital may determine that the number of resident FTEs on a previously settled MCR is incorrect and require adjustment. If this is the case, the CHGME FI (via BCBSA) will request that a reopening (within three years of the NPR) is required by the Medicare FI for any unresolved FTE resident counts’ discrepancy on "full filers".

50. Re-openings (Continued) For low- or no-utilization filers: Children’s hospitals filing low or no-utilization MCRs may request a re-evaluation of resident FTEs confirmed by the CHGME FI based upon their assessment. This re-evaluation must be requested in writing within three-years of the CHGME FI’s final FTE resident count assessment.

51. Appeals Process Although every effort will be made to resolve disputes prior to the release of the CHGME final assessment report, hospitals dissatisfied with their final determination of FTE resident counts where the amount in controversy is greater than $10,000 may appeal to the Medicare Provider Reimbursement Review Board (PRRB).

52. Appeals Process, continued. This formal mechanism of appeal is established under Public Law, 106-310, the CHGME Payment Program authorizing statute, which provides that “the amount so determined shall be considered a final intermediary determination for purposes of applying section 1878 of the Social Security Act and shall be subject to review under that section in the same manner as the amount of payment under section 1886(d) of such Act is subject to review under such section.”

53. Looking Ahead  Success Stories Associated with the Resident FTE Assessment Program  CHGME Payment Program Website (http://www.bhpr.hrsa.gov/childrenshospitalgme)

54. That’s All Folks!