Fellowship Billing Guidelines

Category: Compliance 

Date: August 17, 1999

Reviewed/Revised: April 2013

Purpose

To establish procedures to ensure compliance with CMS guidelines addressing billing for professional services rendered with or by fellows

Policy

I. Fellows in Accredited/Certified Fellowships

A. Services Provided Within the Fellowship Program

1. General Rule

Fellows in accredited residencies or those which are certified by the specialty board may not bill for services provided within the fellowship program, whether or not the physician is otherwise licensed to practice medicine in Virginia, except fellows may bill for services furnished in non-provider settings, such as clinics and physician offices in connection with the fellowship program if all of the requirement in paragraph A.2 below are met.

2. Services in Non-Provider Settings Such as Clinics and Physician Offices

Fellows may bill for services furnished in non-provider settings such as clinics and physician offices in connection with the fellowship program if all of the following requirements are met:

1. The fellow is fully licensed to practice medicine in the Commonwealth of Virginia [the license is on file in the Office Graduate Medical Education and the fellow has malpractice insurance].
2. The time spent in patient care activities in the non-provider setting is not included in teaching hospital’s full-time equivalency resident count for the purpose of direct program payments.
3. No payment is made for the services of a teaching physician.
4. The carrier must apply the physician fee schedule payment rules for payments for services furnished by a resident in a non-provider setting.

B. Moonlighting Services Outside the Scope of the Fellowship Program

1.  General Rule

If approved by the fellowship Compliance Officer, the fellow may participate in moonlighting activities outside the scope of the fellowship program and bill for clinical activities under the following provisions:

1. The fellow is fully licensed to practice medicine in the Commonwealth of Virginia [the license is on file in the Office of Graduate Medical Education] and the fellow has obtained independent malpractice insurance.
2. A separate contract for the moonlighting activities must be executed and delivered by the fellow and the person or entity for whom services will be provided designating the scheduled moonlighting activities and describing the clinical responsibilities of the fellow. The services provided must not be related to the clinical activities of the fellowship and the contract must provide for an absolute separation of the clinical activities of the fellowship and the moonlighting activities.
3. A copy of the executed contract described in paragraph B.1 b) above must be attached to the Eastern Virginia Medical School Resident/Fellow/Intern contract.

2. Moonlighting Services Performed in Hospitals in which the Fellow Has Fellowship Program

1. Moonlighting services performed in hospitals in which the fellow has his/her approved fellowship program may not include any services whatsoever to inpatients. Moonlighting services provided in any such teaching hospitals in which the fellow is training are limited to out-patient or emergency room services, and any services provided must be outside the scope of the fellowship program.
2. The separate contract for the moonlighting activities described in paragraph B1. b) must provide as follows:
   1. The services to be provided are identifiable physician services and meet the conditions for payment of physician services to beneficiaries.
   2. The services performed can be separately identified from those services that are required as part of the fellowship program.
   3. The fellow is fully licensed to practice medicine in the Commonwealth of Virginia.
   4. The services performed can be separately identified from those services that are required as part of the fellowship program.
   5. The fellow is fully licensed to practice medicine in the Commonwealth of Virginia.
3. No payment may be made whatsoever for the services of a teaching physician.
4. The time spent furnishing the services must not be included in the teaching hospital’s full-time equivalency count for the indirect program payment and for the direct program payment.

3. Moonlighting Services Performed in Hospitals other than Hospitals in Which the Fellow has Fellowship Program.

The paid clinical activities conducted in a hospital other than a hospital in which the fellow has his approved fellowship program may include inpatient services but may not include those clinical services for which the fellow is in training. All services provided must be outside the scope of the fellowship program. The time spent furnishing the services must not be included in the teaching hospital’s full-time equivalency count for the indirect program payment and for the direct program payment.

II. Fellows in Non-Accredited/Non-Certified Fellowship Programs

Fellows in training programs which are not accredited by the Accreditation Council for Graduate Medical Education and for which the associated specialty board does not offer certification may bill for in-patient and out-patient clinical activities within their training program. The fellow must be fully licensed to practice medicine in the Commonwealth of Virginia and a copy of the license must be on file in the Office of Graduate Medical Education. A fellowship/chief resident description form must be on file in the Office of Graduate Medical Education for each fellow participating in the program. These forms are available through the Office of Graduate Medical Education and must be attached to the fellow/chief resident Eastern Virginia Medical School contract prior to the beginning of the fellowship.

NOTE: If the fellow is authorized to practice only in a hospital (for example, individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools), special rules may apply with regard to reimbursement. In such cases, please contact the Office of Graduate Medical Education.