CMS Reviewing for Duplicate Intern and Resident Full-Time Equivalents

The Centers for Medicare and Medicaid Services (CMS) announced a Duplicate Interns and Residents Full-Time Equivalents (FTEs) Review project on May 3, 2023.

The primary goal is to identify and resolve duplicate FTEs, which will require Medicare Part A teaching providers to supply documentation to support their claimed FTEs. Myers and Stauffer LC, a CMS contractor, has been contracted to complete reviews of all Intern and Resident Information System (IRIS) duplicates and has begun reaching out to providers.


Teaching hospitals are required to submit IRIS files as part of the Medicare cost report submission. These files list interns and residents—and their assignment periods—also known as rotations. Assignment periods determine FTE counts claimed in the cost report, forming the basis for DGME and IME reimbursement.

CMS maintains an internal master IRIS system that validates IRIS files sent by all providers nationwide and identifies overlaps where multiple hospitals claim reimbursement for the same resident.

IRIS File Format Changes

CMS announced changes to the IRIS file submission files, Inpatient PPS Rule, in federal fiscal year (FFY) 2021. The new file format, IRIS XML format, is required for providers claiming IME and GME FTEs for cost reporting periods beginning on or after October 1, 2021. Prior submissions consisted of two dBase database files, master and assignment.


Hospitals that train residents incur significant costs beyond those associated with providing patient care. The Medicare program makes payments to teaching hospitals for a portion of these added costs through two mechanisms.

The Direct Graduate Medical Education (DGME) payment compensates teaching hospitals for a portion of the costs directly related to training residents. DGME is paid on a per resident amount (PRA) as a separate pass-through payment, separate from the Medicare Severity Diagnosis Related Groups (MS-DRG) payment.

The Indirect Medical Education (IME) payment compensates teaching hospitals for indirect costs involved in training residents. The hospital’s IME payment is determined with a Medicare formula that adds the hospital’s intern-to-bed ratio (IRB) into the calculation.

The payment is an add-on to the basic Medicare prospective payment system (PPS) payment for each hospital discharge. Medicare reimbursement for DGME and IME in part is based on the number of FTE residents the provider trains and the portion of the training time spent working at the provider.

According to Title 42 of the Code of Federal Regulations (CFR) Sections 412.105(f)(1)(iii)(A) and 413.78(b), no resident may be counted as more than one FTE. A significant number of teaching hospital providers have FTE duplicates, also known as IRIS duplicates or overlaps, and are therefore, subject to further review.

IRIS Duplicate or Overlap

An IRIS duplicate or overlap occurs when two or more providers claim the same resident for time totaling more than 100% utilization in either the IME or Unweighted DGME. To avoid duplicates, providers must coordinate their IRIS submissions.

Review Timeline

The CMS contractor will review cost reports with overlaps based on the FFY for which these reports align:

Chart of the review timeline

Cost Reports Affected

For open cost reports—ones that aren’t settled at the time of the review—the IRIS review will be completed and the Medicare Administrative Contractor (MAC) will incorporate necessary adjustments as part of the Notice of Program Reimbursement (NPR) process.

For final settled cost reports where an NPR has already been issued, a Notice of Reopening will be issued by Myers and Stauffer.

Even if a cost report can’t be reopened, the review must be completed because more than one provider could be impacted.

Review Details

Providers will be notified that they have duplicate FTEs subject for review via email that will come from

The email will include:

  • Review and audit notification letter
  • Instructions to access the secure file transfer site
  • Sample overlap report

The provider must complete an authorization form to access the portal and download the hospital-specific overlap report as it contains protected health information (PHI) and personally identifiable information (PII).

Provider Documentation Response and Timeline

Providers have 30 days to respond to the initial documentation request.

The Myers and Stauffer documentation request letter includes examples of acceptable documentation such as detailed rotation or resident assignment schedules that clearly support the period claimed, invoices, personnel documentation, or documents signed by the resident. They will also request an attestation signed by all providers identifying which provider can claim the resident.

Review Completion

After the review, Myers and Stauffer will send a copy of the proposed cost report adjustments for review or a notification that no adjustments are warranted. Once the IRIS overlap duplicate FTE review is completed, changes will be uploaded to the IRIS database and the MAC will incorporate any adjustments into their cost report settlement process, either NPR or RNPR.


Provide documentation requested prior and during the review in a timely manner to Myers and Stauffer. Failure to produce documentation could result in the removal of the FTEs associated with the overlap assignment periods which could lead to a reduction in reimbursement.

We’re Here to Help

To learn more about these reviews or how to approach IRIS overlaps during a review, contact your Moss Adams professional.

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