Physicians in Residency and Fellowship Programs
For Medicare program purposes, the Centers for Medicare & Medicaid Services (CMS) defines "residents" as physicians participating in approved postgraduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital setting, e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools. Where a senior resident has a staff or faculty appointment or is designated, for example, a "fellow," it does not change the resident's status for the purposes of Medicare coverage and payment. As a general rule, the hospital's Medicare fiscal intermediary pays the hospital for services of residents as provider services.
Services Furnished Within the Scope of Approved Training Programs
Medical and surgical services furnished by residents within the scope of their training program are covered as provider services. The term "provider services" includes services furnished within the provider setting and medical and surgical services furnished in a setting that is not part of the provider, where the hospital has agreed to incur all or substantially all of the costs of training in the nonprovider setting. Such services are reimbursed to the hospital by the hospital's Medicare fiscal intermediary and are not separately payable by Part B of the Medicare program. Resident physicians providing services only on this basis do not enroll in Part B of the Medicare program.
Note: Where the provider does not incur all or substantially all of the training costs in the nonprovider setting, and the services are performed by a licensed physician, the services are payable under Part B by the Medicare carrier, and the resident physician may enroll in Part B of the Medicare program.
Services Furnished Outside the Scope of Approved Training Programs
"Moonlighting" Services
Medical and surgical services furnished by residents that are not related to their training program, and that are performed outside the facility where they have their training program, e.g., in an urgent care clinic, are covered by Medicare Part B as physician services where both of the following requirements are met:
- The services are identifiable physician services, the nature of which requires performance by a physician in person and which contribute to the diagnosis or treatment of the patient's condition; and,
- The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed.
When both of these requirements are met, the residents' services are considered to have been furnished by the residents in their capacity as physicians and not in their capacity as residents. Resident physicians meeting these requirements may enroll in Part B of the Medicare program for reimbursement based on the Medicare Physician Fee Schedule Database (MPFSDB).
Medical and surgical services furnished by residents that are not related to their training program, and that are performed in an outpatient department or emergency room of the hospital where they have their training program, are covered as physicians' services where all three of the following criteria are met:
- The services are identifiable physician services, the nature of which requires performance by a physician in person and which contribute to the diagnosis or treatment of the patient's condition;
- The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed; and,
- The services performed can be separately identified from those services that are required as part of the training program.
When these three criteria are met, the residents' hospital outpatient department and emergency room services are considered to have been furnished by the residents in their capacity as physicians and not in their capacity as residents. Resident physicians meeting these requirements may enroll in Part B of the Medicare program for reimbursement based on the MPFSDB.
Resident physicians eligible to enroll in Part B of the Medicare program do so by submitting a CMS 855I enrollment application and, where benefits are reassigned, a CMS 855R enrollment application. The entity to which benefits are reassigned must have enrolled with Medicare by completing a CMS 855B enrollment application. Medicare enrollment forms can be downloaded from the CMS Website: http://www.cms.hhs.gov/CMSForms/
Resident physicians themselves, as well as academic medical institutions and other entities involved in enrolling resident physicians in the Medicare program, must ensure that CMS 855 enrollment application forms are complete and accurate when they are submitted; that they are submitted on the current version of the appropriate CMS-855 form(s); and that they contain all required supporting documentation, including a copy of the resident's license and copies of the National Provider Identifier (NPI) notifications received from the NPI Enumerator for both the resident and the entity to which the resident is reassigning Medicare benefits.
Note that the questions in CMS 855I Section 2.C. "Resident/Fellow Status" must be answered correctly and completely, and that the answers must be consistent both within Section 2.C. itself and with the information provided in Section 4, "Practice Location Information." The name and address of the teaching hospital ("facility") at which the physician is a resident or fellow must be reported in response to Question 1 in Section 2.C., and subsequent questions must be answered in light of the response to Question 1. When this section, or other required sections of the application, are not completed correctly, processing of the application is delayed because the needed information must be developed.
Questions regarding the provider enrollment process may be directed to our Provider Enrollment Department at these telephone numbers:
- 1-877-908-8476 for Wisconsin, Illinois, and Michigan; and,
- 1-866-564-0315 for Minnesota.
Completed enrollment applications for physicians practicing in Wisconsin, Illinois, and Michigan should be sent to: Wisconsin Physicians Service, Medicare Part B, Provider Enrollment Department, P.O. Box 8248, Madison, WI 53708-8248. Applications being sent via courier should be delivered to 1707 W Broadway, Madison, WI 53713-1834.
Completed enrollment applications for physicians practicing in Minnesota should be sent to Wisconsin Physicians Service, Medicare Part B, Provider Enrollment Department, 8120 Penn Avenue South, Suite 200, Bloomington, MN 55431-1394.
Page Last Updated: Tuesday, 15-Jul-2008 10:45:22 CDT
