Appendix D: Clinical Experience and Educational Work Hours and Moonlighting

D. Moonlighting Request Forms

• Moonlight at Emory Healthcare facilities
• Moonlight outside Emory Healthcare
• Questions? Email us at gme@emory.edu

D.1 Clinical and Educational Work Hours

Maximum Hours of Clinical and Educational Work per Week

Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.

Mandatory Time Free of Clinical Work and Education

The program must design an effective program structure that is configured to provide residents with educational opportunities, as well as reasonable opportunities for rest and personal well-being.

Residents should have eight hours off between scheduled clinical work and education periods.

There may be circumstances when residents choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-day-off-in-seven requirements.

Residents must have at least 14 hours free of clinical work and education after 24 hours of in-house call.

Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks). At-home call cannot be assigned on these free days.

Maximum Clinical Work and Education Period Length

Clinical and educational work periods for residents must not exceed 24 hours of continuous scheduled clinical assignments.

Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident education.

Additional patient care responsibilities must not be assigned to a resident during this time.

Clinical and Educational Work Hour Exceptions

In rare circumstances, after handing off all other responsibilities, a resident, on their own initiative, may elect to remain or return to the clinical site in the following circumstances:

• to continue to provide care to a single severely ill or unstable patient;
• humanistic attention to the needs of a patient or family; or,
• to attend unique educational events

These additional hours of care or education will be counted toward the 80-hour weekly limit.

In-House Night Float

Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.

Maximum In-House On-Call Frequency

Residents must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period)

At-Home Call

Time spent on patient care activities by residents on at-home call must count toward the 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one day in seven free of clinical work and education, when averaged over four weeks.

At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.

Residents are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. These hours of inpatient patient care must be included in the 80-hour maximum weekly limit.

D.2 Code of Federal Regulations

§ 415.208 Services of moonlighting residents.

Definition:
For purposes of this section, the term services of moon-lighting residents refers to services that licensed residents perform that are outside the scope of an approved GME program.

Services in GME program hospitals.

1. The services of residents to inpatients of hospitals in which the residents have their approved GME program are not covered as physician services and are payable under § 413.86 regarding direct GME payments.
2. Services of residents that are not related to their approved GME programs and are performed in an out-patient department or emergency department of a hospital in which they have their training program are covered as physician services and payable under the physician fee schedule if all of the following criteria are met:
   • The services are identifiable physician services and meet the conditions for payment of physician services to beneficiaries in providers in § 415.102(a).
   • The resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed.
   • (The services performed can be separately identified from those services that are required as part of the approved GME program.
3. If the criteria specified in paragraph (b)(2) of this section are met, the services of the moonlighting resident are considered to have been furnished by the individual in his or her capacity as a physician, rather than in the capacity of a resident. The carrier must review the contracts and agreements for these services to ensure compliance with the criteria specified in paragraph (b)(2) of this section.
4. No payment is made for services of a ‘‘teaching physician’’ associated with moonlighting services, and the time spent furnishing these services is not included in the teaching hospital’s full-time equivalency count for the indirect GME payment (§ 412.105 of this chapter) and for the direct GME payment (§ 413.86 of this chapter).

Other settings

Moonlighting services of a licensed resident in an approved GME program furnished outside the scope of that program in a hospital or other setting that does not participate in the approved GME program are payable under the physician fee schedule as set forth in § 415.206(b)(1).