Compliance Corner: When Can You Bill For A Newly-Hired Anesthesiologist Under the Medicare Locum Tenens Rules?

Karin Bierstein, JD, MPH
Vice-President for Strategic Planning and Practice Affairs, ABC

As part of our desire to keep both clients and readers up to date, the Communiqué has been printing compliance information since its inception. In the Compliance Corner, we will now formally keep you abreast of the various compliance issues and/or pick out a topic that would be of interest to most of our readers.

The Medicare locum tenens (“place holder”) rules permit physicians to hire substitutes to take over their cases when the regular doctors are temporarily absent and to bill for the substitutes under the regular physicians’ names. Normally, the regular physicians’ group submits claims to Medicare for the locums’ services using the regular doctors’ provider numbers.

Occasionally an anesthesiology practice will ask whether it can use the provider number of a physician who has left the practice to bill for services performed by a doctor hired as a replacement. This scenario has arisen more frequently during the implementation of the new National Provider Numbers, which some carriers have been very slow to issue, or because of carrier delays in linking NPIs with the group number.

The Medicare locums rules are intended, however, to create a limited and temporary exception to the policy disfavoring reassignment of claims. Theoretically, if there were no time limit on the use of a physician’s provider number to bill for his or her replacement, Medicare could be paying for the services of physicians who are not meeting Medicare’s requirements or who have even been excluded from the program.

One of the conditions under which Medicare will pay the group for the services provided by a locums, therefore, is that “the substitute physician … not provide the…services to Medicare patients over a continuous period of longer than 60 days….” (Claims Processing Manual, Chapter 1, Section 30.2.11; http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf. The other conditions are that the regular physician be unavailable, that the Medicare beneficiary seeks services from the regular physician, that the locums be paid on a per diem or similar fee-for-time basis, and that the Medicare claim contain the Q6 modifier designating locum tenens services.)

The Medicare rules explicitly allow the use of the locums rules in situations where the regular physician has resigned from the group and will not be returning, stating “a physician who has left the group and who the group has engaged a locum tenens physician as a temporary replacement may bill for the temporary physician for up to 60 days.” Answering another implicit question, the manual also makes it clear that successive 60-day periods can not be added together by providing that “A new period of covered … services can begin after the regular physician has returned to work.”

Thus, when one physician leaves a practice and is replaced, the group can treat the replacement as a locum tenens for no more than 60 days. It should plan to submit claims using the name and NPI of the replacement physician beginning on or before the 61st day of his or her employment.