Understanding The Ins And Outs Of Insurance Billing For Locum Tenens Assignments

Billing for locum tenens services is an important aspect of healthcare administration, ensuring that healthcare facilities can continue to generate revenue and provide uninterrupted access to quality care for patients. Locum tenens physicians are temporary replacements for absent regular physicians, and their services can be billed to insurance providers such as Medicare and Medicaid. The billing process for locum tenens services depends on whether the services are classified as replacement or supplemental. Replacement services are provided by locum tenens physicians filling in for a regular physician's absence, typically for 60 days or less, while supplemental services are used when a practice needs additional support beyond their current staff or for longer periods. Proper billing methods must be followed, and guidelines such as the Medicare Rule and the use of modifiers like Q6 are crucial to ensure compliance and accurate reimbursement.

Locum tenens billing basics

Locum tenens physicians are often used to fill in for absent doctors or nurse practitioners, ensuring patients continue to receive quality care and that revenue isn't lost. Billing for locum tenens services correctly is essential to avoid losing money.

The first step is to identify whether you need a replacement or supplemental physician. A replacement locum tenens physician fills in for your regular physician for a short period, typically 60 days or less. Supplemental services, on the other hand, are used when you need an additional physician to grow your practice or require a replacement for more than 60 days.

Billing for Replacement Services

For replacement services, the regular physician bills and receives payment for the substitute's services as if they performed them. These services should be reported with the modifier Q6, and the time period cannot exceed 60 days. The 60-day count starts when the locum tenens physician sees their first patient, not from the date of the regular physician's absence. The regular physician arranges coverage for no more than 60 continuous days and then enters the HCPCS code modifier Q6 after the procedure code during the billing process.

Billing for Supplemental Services

When billing for supplemental services, the entity receiving payment and the person furnishing the service are jointly and severally responsible for any Medicare overpayment. The person providing the service must have unrestricted access to claims submitted by an entity for their services. The supplemental provider completes the necessary applications to bill for services with private carriers and the state's Medicaid program. They will also need to complete Medicare's Form 855R to allow billing under their services.

Private Payors, Medicaid, and Medicare

Many private payors and state Medicaid programs follow Medicare guidelines, but it's good practice to verify each program independently. Enrolling your locum tenens provider with your three to five largest payors will allow you to bill for most of the services they provide. Understanding your patient population and the main insurance carriers involved is crucial.

Medicare rules and guidelines

Definition of Locum Tenens:

Locum tenens, meaning "holding a place" in Latin, refers to contracted physicians who substitute for a physician who has left the practice or is temporarily unavailable due to medical leave, vacation, or other reasons.

Medicare Reimbursement Rules:

The Centers for Medicare and Medicaid Services (CMS) allow payment for services provided by locum tenens physicians, but specific guidelines must be followed. The rule published by CMS regarding reimbursement is specifically for physician services and is only applicable to Medicare.

Time Limitations:

A locum tenens physician can provide services to Medicare patients for a continuous period of no longer than 60 days. The 60-day count starts on the first day the locum tenens physician sees a patient. The only exception to this rule is when the regular physician is called for active duty in the Armed Forces.

Billing Procedures:

For locum tenens engagements expected to last less than 60 days, the regular physician or physical therapist can receive Part B payment for covered visit services of a substitute physician. The regular physician bills and receives payment for the substitute physician's services, using modifier Q6 to indicate a locum tenens situation. The substitute physician is paid on a per diem or similar fee-for-time basis.

For engagements extending beyond 60 days, organizations have two options: enroll the locum tenens provider in the organization's contracted payer mix (including Medicare, Medicaid, commercial payers, etc.) and bill under the locum tenens physician's NPI number, or briefly bring back the absent provider to reset the 60-day window and reuse the same locum tenens physician.

Enrollment and Credentialing:

The locum tenens physician does not need to be enrolled in the Medicare program but must have a National Provider Identifier (NPI) and an unrestricted license to practice in the state. They must also go through the Medicare credentialing process and be approved as a credentialed Medicare provider before seeing Medicare patients.

Record-Keeping:

The practice must keep a record of each service provided by the locum tenens physician, along with their NPI or Unique Provider Identification Number (UPIN). This record must be made available to Medicare upon request.

Non-Physician Practitioners:

It is important to note that the locum tenens provision is specifically for physician services. Services provided by non-physician practitioners, such as nurse practitioners or physician assistants, cannot be billed under the locum tenens provision.

By following these Medicare rules and guidelines, healthcare organizations can effectively bill for locum tenens services and ensure compliance with reimbursement regulations.

Medicaid and commercial payers

When it comes to Medicaid and commercial payers, there are a few key considerations to keep in mind. Firstly, it's important to validate with individual payers whether they have adopted the Medicare rule for locum tenens billing. If they haven't, you'll need to understand the specific rules that govern their reimbursement of locum tenens providers.

The Center for Medicare and Medicaid Services (CMS) has set out guidelines for locum tenens billing, which are worth noting. They state that a locum tenens physician can provide services to Medicare patients for a continuous period of no longer than 60 days. The only exception to this rule is when the regular physician is called for active duty in the Armed Forces.

If the locum tenens engagement is expected to last less than 60 days, the regular physician or physical therapist can receive Part B payment for covered visit services of a substitute physician or therapist. The regular physician or therapist must be unavailable, and the Medicare beneficiary must seek to receive services from them. The regular physician or therapist pays the substitute on a per diem or similar fee-for-time basis.

For engagements expected to extend past 60 days, organizations have a few options. They can begin enrolling the locum tenens provider in the organization's contracted payer mix (including Medicare, Medicaid, and commercial payers) before their start date or as soon as possible. At the end of the 60-day window, billing can occur under the locum tenens physician's NPI number as if they were permanent. Alternatively, the absent provider can return briefly to reset the 60-day window, allowing for the reuse of the same locum tenens physician or a new one.

It's important to remember that claims must contain the NPI of the regular physician, not the locum or substitute. The CPT/HCPCS codes must also have the modifier Q6 appended, indicating that the billed services were furnished by the locum.

Enrolling locum tenens providers

Locum tenens providers are temporary physicians who fill in for absent doctors or nurse practitioners. They are usually hired to ensure patients continue to receive quality care and that revenue isn't lost due to a vacancy.

When billing for locum tenens providers, it's important to remember that the rules governing reimbursement for their services are outlined by Medicare and only apply to Medicare and physician services. For billing inquiries relating to Medicaid or commercial payers, it's necessary to validate with individual payers if they have adopted the Medicare rule and, if not, understand the specific rules that govern their reimbursement of locum tenens providers.

The Center for Medicare and Medicaid Services (CMS) has stated that a locum tenens physician can provide services to Medicare patients over a continuous period of no longer than 60 days. The only exception to this rule is if the regular physician is called for active duty in the Armed Forces.

For locum tenens engagements expected to last less than 60 days, CMS has provided guidelines that enable the regular physician or physical therapist to receive Part B payment for covered visit services of a substitute physician or physical therapist. The regular physician or physical therapist must be unavailable to provide the service, and the Medicare beneficiary must have arranged or sought to receive the services from the regular physician or physical therapist. The regular physician or physical therapist pays the substitute for their services on a per diem or similar fee-for-time basis.

The Q6 Modifier is appended after the CPT code to indicate that the billed services were furnished by the locum or substitute physician. This is added in box 24D of the CMS-1500 claim.

For locum tenens engagements expected to extend past 60 days, organizations can choose one of two routes:

• Enroll the locum tenens provider in the organization's contracted payer mix (Medicare, Medicaid, commercial payers, etc.) prior to their start date or as soon as possible upon starting. At the end of the 60-day window, bill under the locum tenens physician NPI number as if they were a permanent physician.
• The absent provider may return to the practice for a brief period, resetting the 60-day window and allowing reuse of the same locum tenens physician or a new one for another 60-day engagement.

It is recommended to begin the payer enrollment process for a locum tenens provider prior to their arrival at the facility/practice if their services are anticipated to extend past 60 days.

Billing for replacement vs supplemental services

Locum tenens is a Latin phrase that means "placeholder". In healthcare, a locum tenens provider fills in for a physician or nurse practitioner when they are absent. The billing process for locum tenens services depends on whether the provider is offering a replacement or supplemental service.

Replacement Services

Replacement services are used when a regular physician is unavailable for a short period, typically 60 days or less. In this case, the regular physician arranges coverage and bills for the locum tenens services as if they performed them. The regular physician will receive payment for the substitute's services and pay the substitute a fixed amount per day. This arrangement can be made for up to 60 days or until the regular physician returns, whichever comes first.

Supplemental Services

Supplemental services are used when a practice needs to grow and requires the services of a physician in addition to the current staff. In this case, the locum tenens provider is enrolled in the standard Medicaid and private payer process required by the state and insurance carrier. The locum tenens provider completes the necessary applications to bill for services with private carriers, the state's Medicaid program, and Medicare Form 855R. The entity receiving payment and the locum tenens provider are jointly responsible for any Medicare overpayment.

Billing Process

When billing for locum tenens services, it is important to identify whether the services are replacement or supplemental. For replacement services, the regular physician bills using their own National Provider Identifier (NPI) and appends the modifier Q6 to indicate that a locum tenens provider is filling in. For supplemental services, the locum tenens provider bills using their own NPI. It is important to note that billing requirements may vary depending on the state and insurance carrier, so it is recommended to verify the specific rules and guidelines.

Frequently asked questions