1) 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.
Sample Answer
) Medicare Payment for Physician Services in Teaching Settings
Medicare pays for physician services in teaching settings through the Medicare Physician Fee Schedule (PFS) under specific criteria, otherwise, these services are covered as provider services and paid through Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME) payments.
Services Furnished by Non-Resident Physicians and Residents
For a service to be billed under the Medicare PFS, thus compensating the teaching physician or group, one of the following criteria must be met:
Personally Furnished by a Physician: The service is furnished solely by a physician who is not a resident.
eaching Physician Presence: If a resident participates in the service, the teaching physician must be physically present during the critical or key portions of any service or procedure for which payment is sought.
For Evaluation and Management (E/M) services, the teaching physician must generally be present in person during the portion of the service that determines the level of service billed.
For surgical, high-risk, or complex procedures, the teaching physician must be present during all critical portions and immediately available for the entire service.
Exceptions for Primary Care
An important exception allows for the payment of certain primary care services furnished by a resident without the physical presence of the teaching physician. This is permitted when the services are provided in a primary care center that is part of an approved GME program, provided:
The services are E/M services or certain other services specified by CMS.
The teaching physician reviews the resident's services or is immediately available to the resident.
The resident is responsible for the management of the patient.
The teaching physician sees the patient at least three times per year.
Specific Requirements for Anesthesia Services
For anesthesia services provided in a teaching setting to be paid under the PFS, the teaching anesthesiologist must be involved in one of the following:
The training of a resident in a single anesthesia case.