BHPR -

Children’s Hospitals Graduate Medical Education Payment Program
Guidance
FTE Resident Count Acceptance for Hospital’s Initial Application
July 8, 2003

printer-friendly FTE Resident Count Program Alert (pdf)

Overview

The CHGME PP awarded a contract to the Blue Cross Blue Shield Association (BCBSA) to assess the FTE resident counts reported by children’s hospitals participating in CHGME PP on their initial FY 2003 applications for funds. The CHGME fiscal intermediaries (FIs) working under this contract generated final FTE resident reports used to make the final determination of payments in FY 2003. This effort resulted in comprehensive and timely FTE resident count reports addressing the CHGME PP statutory mandate that the Secretary determine any changes to FTE resident counts reported by the hospitals in the fiscal year for which payments are being made. These final reports were received by each of the children’s hospitals that applied for funds in FY 2003.

The CHGME PP FTE assessment process introduces a new source of reviewed FTE resident counts that needs to be integrated with (1) CHGME PP statutory requirements and published policy related to the acceptance of FTE resident counts, (2) FTE resident counts generated by the Medicare FIs, and (3) FTE resident counts resulting from an appeal to the Provider Reimbursement Review Board (PRRB) and/or the HRSA administrator.

This guidance describes that integration and provides clarification and guidance to hospitals on completing the initial CHGME PP application by providing answers to the following questions:

§ For children’s hospitals that file full Medicare cost reports (MCRs), which FTE resident counts will be used by the Program to determine estimated initial payment [the counts from the MCR (worksheet E3 Part 4) or those reported by the CHGME FI]?

§ For children’s hospitals filing low or no utilization MCRs, which FTE resident counts will be used to determine initial payments?

§ How will decisions pending before the Provider Reimbursement Review Board (PRRB) be incorporated into a hospital’s initial application?

§How will the status of the Medicare cost report (MCR) and the CHGME FI FTE reports be identified in the hospital’s application?

§ How will any discrepancies between FTE resident count assessments conducted by the Medicare FIs and those conducted by the CHGME FI be incorporated into a hospital’s initial application?

Question 1: For children’s hospitals that file full Medicare cost reports (MCRs), which FTE resident counts will be used by the Program to determine estimated initial payment [the counts from the MCR (worksheet E3 Part 4) or those reported by the CHGME FI]?

Beginning in FY 2004, for hospitals filing full MCRs, the CHGME PP will use FTE resident counts from the CHGME FI’s FTE final FTE report unless the MCR is settled by Medicare by the initial application due date, in which case FTE resident counts from the settled or resettled) MCR will be used.

NOTE: The FTE resident count from the settled (or re-settled) MCR will be used if the MCR is settled (or re-settled) by the initial application due date even if there is a discrepancy between the FTE resident counts on the MCR and the CHGME FI FTE report.

In the case of hospitals using FTE resident counts that have not yet been assessed by the CHGME FI, FTE resident counts from the “as filed” MCR will be used. As was done in past CHGME PP applications, the hospital will need to include in their CHGME PP application information that is not on the MCR but is required in the HRSA form 99-1 (e.g., residents within and beyond their initial residency period, unweighted dental and podiatric residents).

The FTE resident counts from settled (by initial application due date) and from as filed (never been assessed) cost report periods reported in the hospital’s application must match the numbers on the Worksheet E 3 Part 4 of the hospital’s relevant MCRS(s).

For “as filed” MCRs:

1. In the event there is a discrepancy between the Wworksheet E3 Part 4 and the hospital’s initial application, the hospital will be required to submit an explanation of the difference in writing to the CHGME PP.

2. In the event that information appears on the worksheet E3 Part 4 that is different from FTE counts previously assessed by the CHGME FI (e.g., the cap), the program will use the FTE resident count from the CHGME FI’s FTE final report.

NOTE: This FTE resident count acceptance hierarchy is essentially the same as the one included in the CHGME PP’s final Federal Register notice published July 20, 2001 (FTE resident counts were accepted from the following sources: 1) settled MCRs, 2) the Medicare FI’s report, and 3) the as-filed MCR. For theFY 2004 initial application, the there is a CHGME FI FTE final >report is used >instead of a Medicare FI report.

Question 2: For children’s hospitals filing low or no utilization MCRs, which FTE resident counts will be used to determine initial payment?

Beginning with FY 2004, FTE resident counts submitted by hospitals filing low/no utilization MCRs in their initial application should match the CHGME FI’s FTE most recent final FTE resident report. For year(s) where the CHGME FI has not assessed the FTE resident counts, the hospital will submit its FTE resident counts in its initial application as it has done in the past (i.e., submit FTE resident counts from their records). As has previously been the case, the hospital is required to comply with the documentation requirements and counting methodology described in 42 CFR 413.86 and must certify that its numbers are correct as required by the CHGME PP application guidance.

Example

Children’s Hospital A submitted FTE resident counts for the 1996 (cap), 2000, 2001, and 2002 cost report periods on its FY 2003 initial application. These FTE resident counts were reviewed by the CHGME FIThe CHGME FI reviewed these FTE resident counts and . a A final FTE assessment report was submitted to CHGME PP and the hospital.

The hospital’s cost reporting period is July 1 – June 30. In preparing its FY 2004 initial application, the hospital decided to include the FTE resident counts from its 2003 cost report period (the most recently completed cost reporting period at the time of the initial application due date – August 1, 2003).

In preparing its FY 2004 initial application, Children’s Hospital A should use the FTE resident counts from the CHGME FI’s FY 2003 final report to complete HRSA 99-1 sections 1 (cap, 1996), 5 (previous cost report period, 2002) and 6 (2 years prior to most recently completed current year, 2001). Section 4 (most recently completed cost report period, 2003) will be based on FTE counts that have not yet been reviewed by the CHGME FI.

Question 3: How will decisions pending before the Provider Reimbursement Review Board (PRRB) be incorporated into a hospital’s initial application?

In a situation where the hospital elected to utilize the PRRB and the board PRRBB decision relates to a Medicare cost reporting period that will be used in the initial application, the CHGME PP will use the FTE resident counts from the CHGME FI’sFTE final report or the latest settled (or resettled) MCR until such time as the issue is resolved – this resolution may involve the PRRB, the HRSA Administrator, and the court system.

If the issue is resolved and the resolution is in agreement with the PRRB decision by the initial application due date, any necessary revisions will be made to the hospital’s FTE resident counts. These revised counts will be used in the hospital’s initial application.

If the issue is resolved and is not in agreement with the PRRB decision or the issue is not resolved by the initial application due date, the FTE resident counts used in the initial application for the upcoming year will be based on the FTE resident counts from the CHGME FI FTE final report or the latest settled (resettled) MCR.

NOTE: Any revisions to the CHGME FI FTE final reportresident counts will be applied to the calculation of the hospital’s payment within that fiscal year. Any adjustments will not be applied to payments received by the hospital in previous fiscal years.prospectively (i.e., from the point in time when they are incorporated into the determination of payments forward) not retrospectively.

Question 4: How will the status of the Medicare cost report (MCR) and the CHGME FI FTE reports be identified in the hospital’s application?

Hospitals participating in the CHGME PP will have report a status code assigned to describing the status of the Medicare cost reports or the status of the CHGME FI FTE final reports they for those MCRs they include in their CHGME PP initial application.

Hospitals filing low/no utilization MCR will use the following codes when reporting the status of the Final Reports used in their CHGME PP applications:

L or N (Low or No)

This status refers to FTE counts submitted by the hospital in their initial application that have not been reviewed by the CHGME FI. Typically these FTE counts will reflect the hospital’s most recently completed cost report period. The “L” and “N” status codes have been used in previous CHGME PP application cycles.

C (Complete)

This status refers to the FTE counts coming from a finalized CHGME FI report (Final Report)

R (Re-Issue)

This status refers to FTE counts coming from a CHGME FI FTE report that has been re-examined based on request from the children’s hospital and then re-issued.

Hospitals filing full MCRs will use the following codes when reporting the status of the MCRs used in their CHGME PP applications:

AF (As Filed)

This status refers to cost reports that have been submitted by the hospital to the Medicare FI but have not yet been reviewed

P (Preliminary)

This status refers to FTE counts that have been assessed by the CHGME (or Medicare) FI where the cost report has not yet been settled (NPRed)

S (Settled)

This status refers to cost reports that have been settled (NPRed) by the Medicare FI

S/R/P (Settled, Re-opened, Preliminary)

This status refers to cost reports that have been settled (NPRed), re-opened by either the hospital or the Medicare FI, where the FTE counts have been assessed by the CHGME (or Medicare) FI

S/R/RS (Settled, Re-opened, Re-settled)

This status refers to cost reports that have been settled (NPRed), re-opened by either the hospital or the Medicare FI, and re-settled by the Medicare FI.

Question 5: How will any discrepancies between FTE resident count assessments conducted by the Medicare FIs and those conducted by the CHGME FI be incorporated into a hospital’s initial application?

The CHGME FI will provide the Medicare FI with a copy of the CHGME FI FTE fFinal Rreport for each year that the FTE resident assessment is completed along with a copy of their work papers. The Medicare FI should review the documentation and results supplied by the CHGME FI and, upon approval of the CHGME FI’s work, incorporate the CHGME FI findings into the Medicare database and generate a revised worksheet E3 part 4 that can be included by the hospital in its applications to the CHGME PP.

There are a few situations where this exchange of information may become more complicated and require intervention/assistance from BCBSA and/or CMS when needed/appropriate.

1. FTE resident counts have been reviewed/assessed by both the CHGME and Medicare FIs. [same BCBS subcontractor (e.g., different offices within UGS); different BCBS subcontractors (e.g., UGS and Trailblazer); or BCBS subcontractor and a non-BCBS FI (e.g., Trispan and Mutual of Omaha)], Tthere are differences in the FTE review results and both parties believe that their FTE assessment is the “most accurate” based on their review.

In this case, the hospital should work with both the CHGME and Medicare FIs to resolve these differences so that, ultimately, there is not a discrepancy between the MCR (Worksheet E3 Part 4) and the CHGME FI Ffinal Rreport. In the event that such a discrepancy exists and cannot be resolved by the initial application due date, the CHGME PP will accept the FTE resident counts from the CHGME FI final report unless the MCR is settled (or re-settled) by the initial application due date in which case the FTE counts from the settled (or re-settled) cost report are used.

2. A Medicare FI has assessed the FTE resident counts and the work papers have been provided to the CHGME FI who will use them to develop the final FTE report. If the CHGME FI has some questions about the Medicare FI’s findings, he/she will try to work with the Medicare FI to resolve these issues so that, ultimately, there is not a discrepancy between the MCR (Worksheet E3 part 4) and the CHGME FI final report. In the event that these issues cannot be resolved, the CHGME PP will accept the FTE resident counts from the CHGME FI final report unless the MCR is settled (or re-settled) by the initial application due date, in which case the FTE resident counts from the settled (or re-settled) cost report will be used.

NOTE: Hospitals filing full MCRs should try to ensure that there is no discrepancy between the MCR and the CHGME FI FTE final report by the time a cost report is settled (or re-settled) , if it has been reviewed by the CHGME FI there is no discrepancy between the MCR and the CHGME FI FTE report. They are also expected may need to monitor the exchange of information between the CHGME and Medicare FIs and to intervene/facilitate when needed. They should be aware of any situations where there is a potential problem in this exchange of information and should make every effort to provide assistance, calling on the CHGME PP staff as needed.

APPENDIX A:

Potential Scenarios Related to MCR Status, the CHGME FI FTE Final Report,
and the CHGME PP Application

Scenario 1: MCR Settled at Time of Reconciliation Review and Re-opened at Time of Initial Application

If the MCR is re-opened by the application due date, CHGME PP will accept the FTE resident counts from the CHGME FI FTE final FTE report.

If a desk check was conducted at the time of review, the CHGME FI will conduct a desk review during the assessment of the FTE counts provided in the initial application during their normal course of CHGME review (Oct. – March); the results of this review will be reported to CHGME PP and used in the reconciliation application for the upcoming year. The hospital should take the lead in coordinating this review with the Medicare FI by assessing such issues as:1) what is the scheduled/anticipated re-settlement date?; 2) Does the Medicare FI plan to assess the FTE counts as part of the re-opening? If so, can that be coordinated with the CHGME FI’s review?

If a desk review was performed, the CHGME FI will work with the Medicare FI to incorporate the results of their findings into the MCR so that the worksheet E3 part 4 of the re-settled cost report matches the findings included in the CHGME FI’s final report. The timeframe for this coordination/follow-up will depend on the Medicare FI’s schedule for re-settling the cost report.

If the Medicare FI plans to re-assess the FTE resident counts as part of the re-opening, the CHGME FI will work with them to try to ensure that the findings from the two assessments are the same. Any differences in the results of the two assessments will be resolved by the two FIs and the final results will be reported to the CHGME PP and the hospital. In the event that these differences cannot be resolved, the CHGME PP will accept the FTE resident counts from the CHGME FI FTE final report unless the cost report is re-settled and will contact CMS to alert them of the differences when appropriate.

NOTE: In all the above situations, Iif the cost report is re-settled by the initial application due date, the CHGME PP will use the #s from the settled cost report.

The status of the cost report/FTE counts should be reported on the initial application as “Settled/Re-opened/Preliminary” (S/R/P) or “Settled/Re-opened/Re-settled” (S/R/RS), whichever is appropriate.

Scenario 2: MCR is “Open” Not Settled at Time of Reconciliation Review and Settled at Time of Initial Application

If the cost report is settled by the initial application due date, the CHGME PP will accept the FTE resident counts from the settled Medicare cost report, even if there is a discrepancy with the CHGME FI’s FTE final report.

If the CHGME FI’s final report doesn’t match the settled MCR, the hospital will work with both the CHGME and Medicare FIs to incorporate their findings into the MCR (e.g., through a re-opening).

The status of the cost report/FTE counts should be reported as “Settled” (S) or “Settled/Re-opened/Re-Settled” (S/R/RS) – whichever is appropriate -- on the initial application.

Scenario 3: Settled at Time of Reconciliation Review and Initial Application

In this case a desk check (or possibly a desk review) would have been performed by the CHGME FI. If the settled MCR (Worksheet E 3 Part 4) doesn’t match the final CHGME FI FTE Final Report assessment report, the CHGME PP will accept the FTE resident counts from the settled MCR. The hospital will work with the CHGME and Medicare FIs to incorporate their findings into the MCR (e.g., through a re-opening).

In order for the CHGME PP to accept the FTE resident counts from the CHGME FI’s FTE final report, the settled cost report would need to be re-opened by the initial application due date. According to the current BCBSA methodology (Exhibit T), the Medicare FI is requested to re-open the MCR in question by May 1 of the current FY.

The status of the cost report should be reported as “Settled” (S) or “Settled/Re-opened/Re-settled” – whichever is appropriate -- on the initial application.

Scenario 4: MCR is “Open”Not Settled at Time of Reconciliation Review and Initial Application

In this case, the CHGME FI would have performed a desk (or field) review. The CHGME PP will accept the FTE resident counts from the CHGME FI’s FTE final report. If the MCR (worksheet E3 part 4) doesn’t match the CHGME FI’s FTE final report, the CHGME FI will work with the Medicare FI to incorporate their findings into the MCR so that the FTE resident counts match by the time the MCR is settled.

The status of the MCR/FTE resident count should be reported as “Preliminary” (P) or “Settled/Re-opened/Preliminary” (S/R/P) on the initial application for the upcoming year.