How to Bill for a Non-Credentialed, Temporary, or Substitute Hire

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There are two billing options available for non-credentialed providers in this circumstance—locum tenens arrangements and reciprocal billing arrangements.

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Locum tenens Billing Arrangements

Locum Tenens – Commercial Insurance Carriers

Locum physician services can be billed under the NPI of the doctor absent, with the -Q6 modifier (service provided by a locum physician) added to each CPT code on the claim. If the locum physician performs post-op services in the global period—the substitute services do not need to be identified on the claim. Practices must maintain a record of patients seen by the locum physician (including the locum’s NPI), and this listing should be made available to commercial insurance carriers, if needed.

The on-staff physician compensates the locum physician on a similar fee-for-visit or per-diem basis. The identification of the locum is mostly used for auditing, to confirm provided services—and not for payment purposes. Non-coverage notifications should be given in the on-staff physician’s name.

Locum tenens – Medicare Rule

Medicare’s requirement is that an on-staff physician can bill and receive payment (when assignment is accepted) for a substitute physician’s services as though the on-staff physician performed them. If you have an on-staff physician who has left your practice and is unable to provide services, locum tenens billing may also be used. The -Q6 modifier must also be added to each CPT code on the claim.

This Medicare rule applies to on-staff physicians and cannot be used for mid-levels. A 60-day consecutive limit applies
for each locum physician—beginning from the first patient seen (even if patients aren’t seen certain days when
physician is on vacation, has days off, etc.) After the 60-day limit expires, a practice may no longer bill for that locum physician. If services still are needed after this time, the practice must employ a different locum physician. New on-staff physician hires cannot be considered locum physicians.

Reciprocal Billing Arrangements

Reciprocal Billing Definition: A reciprocal billing arrangement is an agreement between physicians to cover each other’s practice when the regular physician is absent. This is usually an informal arrangement and is not required to be in writing.

Reciprocal Billing – Commercial Insurance Carriers

Verify with your contracted health plans to make sure you are following your contract and billing policies for reciprocal billing. If you do not know what is required by a specific payer, again, it is a good rule of thumb to follow Medicare policy.

Reciprocal Billing -Medicare

Services may be submitted under a reciprocal arrangement if all the following criteria are met:
• The regular physician is unavailable to provide the services
• The patient has arranged or seeks to receive care from the regular physician
• The substitute physician does not provide services to the beneficiary over a continuous period of more than 60 days
• The regular physician submits the claim with a Q5 modifier with each service (CPT) code

Reciprocal billing is another option for urgent cares if locum tenens arrangements are unavailable or are no longer an option. Like locum tenens, reciprocal billing arrangements cannot extend past 60 days. These stop-gap measures are meant to be a temporary solution, and Medicare assumes your clinic is working toward employing regular credentialed and contracted physicians to provide services.

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To keep the edge on your offices fiscal health, check out our article on INCIDENT TO BILLING  or check out our PROVIDER CREDENTIALING SERVICES.

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