Coverage for Services Furnished by an Intern or Resident

Services furnished within the Scope of an Approved Training Program

Medical and surgical services furnished by the intern or resident, within the scope of training program are covered as provider services and paid by Medicare through Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME) payments. These services may not be billed or paid under the Medicare PFS. If you are in an approved program and training in a nonprovider setting, the services furnished are payable in one of the following ways:

1)  Through DGME and IME payments to the hospital(s), if, among other things, you:

Provide patient care activities and the hospital(s) incurs your salary and fringe benefits during the time spent in the nonprovider setting; or For DGME purposes – Spend time in certain nonpatient care activities in certain nonprovider settings and the hospital(s) incurs your salary and fringe benefits  during the time spent in the nonprovider setting; or

2)  Through the Medicare PFS if, in part, the regulations concerning the hospital’s receipt of DGME and IME payments are not met for the time you spend in a nonprovider setting, and the time you spend in the nonprovider setting is not counted by the hospital for DGME and IME payment purposes.

Services furnished  Outside the Scope of an Approved Training Program (Moonlighting)

Medical and surgical services that the intern or resident, furnish that are not related to training program and furnish outside the facility where you have the training program are covered as physician services when    the    requirements    in    the    first    two    bullets    listed below are met. Medical and surgical services that you furnish that are not related to your training program and furnish in an outpatient department or emergency room of the hospital where you are in a training program are covered as physician services when the requirements in all three of the  bullets listed below are met. When these criteria are met, the services are considered furnished in your capacity as a physician, not  in your capacity as an intern or resident.

• The    services    are    identifiable     physician    services, the nature of which require performance by a physician in person and contribute to the diagnosis or treatment of the patient’s condition;

• You are fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed; and

• The services furnished can be separately    identified     from    those    services that are required as part of the training program