Medicare IME Review
Teaching hospitals are required to create a “shadow bill” in order to receive the Indirect Medical Education (IME) payment from CMS when the patient is enrolled in a Medicare Advantage plan. The issue of ‘Shadow Billing’ is a consistent problem for teaching hospitals with the burden of the provider having to identify the IME claims and coding the affected claim correctly before processing.
Medicare Advantage Plan Nuances
Medicare Advantage plans pay according to the negotiated rates with the hospital, and CMS provides the additional IME component of the DRG payment. Both must receive a bill. The bill that is sent to traditional Medicare is often referred to as a "shadow" bill. An underpayment issue can follow due to the fact that two ‘primary’ bills must be generated. Often once the main Medicare Advantage plan pays, it is easy for the balance to be written-off (i.e. not recalling that a payment from traditional Medicare is due the facility as well). Another underpayment opportunity lies in the fact that claims may be registered incorrectly (i.e. Blue Cross instead of Blue Cross seniors) and no "shadow" bill is ever sent out.
Comprehensive, Prompt Reviews
PMMC provides an extensive review of Medicare Advantage claims that quickly identifies the claims appropriate for rebilling. By calculating the expected reimbursement and comparing it to the payments received, PMMC is able to identify Medicare Advantage claims that did not have a “shadow” bill sent to the Medicare Contractor. By submitting a “shadow” bill to the Medicare Contractor, the Hospital will receive additional reimbursement for the IME (Indirect Medical Education) services it provides.
Nominal Efforts Required
With experience in various patient accounting systems, claims processing, common working files, and data extraction methodologies, PMMC’s review has a minimum impact on the Hospital’s staff. After PMMC receives the client’s data, most reviews are completed in a few weeks. This is accomplished through a balanced approach that leverages automation and a dedicated team that specializes in this area.
Data Integrity and Security
PMMC maintains strict security measures to keep client data safe. Following HIPAA guidelines, PMMC security measures include data encryption systems, secure file transfer protocols, passwords and background checks on employees.