1) Please provide a comprehensive overview of how Medicare pays for physician services in teaching settings, detailing the specific criteria that must be met for payment under the Medicare Physician Fee Schedule (PFS) for services furnished by both non-resident physicians and residents, including any exceptions for primary care and the specific requirements for anesthesia services.
2) Elaborate on the guidelines and specific requirements that must be met for medical and surgical services furnished by an intern or resident to be covered as physician services when they are performing "moonlighting" activities, distinguishing between services provided outside the training facility versus those in an outpatient department or emergency room of the training hospital.
3) Explain the core intent behind the establishment of the Accreditation Council for Graduate Medical Education's (ACGME) Clinical Learning Environment Review (CLER) program as part of its Next Accreditation System (NAS), and describe the anticipated outcomes and benefits of its implementation for graduate medical education (GME) settings.
4) Describe each of the six specific areas of focus for the Clinical Learning Environment Review (CLER) program, outlining what each area encompasses in terms of resident and institutional engagement.
5) Describe the multifaceted responsibilities of the Graduate Medical Education Committee (GMEC) within a sponsoring institution, explaining how it functions as an administrative system to ensure the educational quality of residency programs, including its role in monitoring compliance, reviewing programs, and facilitating continuous quality improvement efforts.
6) Provide a thorough explanation of the proposed performance-based metrics for the future funding of graduate medical education (GME) as presented by Caverzagie, et al., including the foundational categories they identified and their process for metric development.
Coverage for Resident "Moonlighting" Activities
"Moonlighting" refers to the professional services provided by an intern or resident outside the scope of their approved GME program. The coverage guidelines for these services under Medicare depend heavily on where the service is furnished.
Services Provided Outside the Training Facility (or in distinct non-provider sites)
When a resident provides medical or surgical services outside the facility where they receive their GME training (e.g., at a different, unaffiliated clinic or hospital), these services can be covered and billed as physician services under the following requirements:
Licensure: The resident must possess a full and unrestricted medical license to practice independently in the state where the services are furnished.
Independent Billing: The services must be billed in the resident's name (or the group they are employed by) using their own billing number (NPI).
Non-Program Activity: The services must be outside the scope of their residency program, meaning they are not required or credited toward their training.
Sample Answer
. Medicare Payment for Physician Services in Teaching Settings
Medicare pays for physician services in teaching settings primarily through the Medicare Physician Fee Schedule (PFS), but specific rules exist to distinguish between services rendered by a resident and those provided by an attending (non-resident) physician.
Criteria for Non-Resident (Attending) Physician Payment under PFS
For an attending physician's services to be paid under the PFS, the services must meet the following criteria:
Physical Presence and Direct Involvement: The attending physician must be present during the key portion of the service (e.g., critical or major part of a surgery, complex procedure) and immediately available to render assistance throughout the service.
Documentation: The attending physician must personally document their presence and participation in the resident's notes or create their own separate documentation, indicating the extent of their involvement.