Locum Tenens Billing

Doctors are humans. They get sick, take vacations, go on maternity leave, or need time to sharpen their skills with continuing medical education. And when a doctor can’t be there, s/he uses a substitute physician, commonly known as locum tenens.

However, there are some common misconceptions when billing for a locum tenens. CMS (Centers for Medicare and Medicaid) has specific billing guidelines; just because you’re using a locum tenens agency doesn’t mean they consider your substitute physician a locum tenens for billing purposes.

Note: Commercial payors often have their own guidelines. Stay tuned for another post to learn more about using locum tenens with commercial payors.

Allowed by CMS

Using locum tenens for physicians who are out due to:

  • Illness

  • Vacation

  • Leave of absence

  • Active duty

  • CME (Continuing Medical Education)

  • Recently leaving the practice (certain restrictions apply)

  • Locum tenens can provide up to sixty consecutive days of service for one physician

If you meet these guidelines, you can bill the locum tenens with a modifier under the regular physician’s provider number.

CMS Prohibits the Use of Locum Tenens for:

  • More than 60 consecutive days for one physician

  • Staff shortage rather than adding regular physicians

  • Physicians who are in the credentialing process

  • A deceased physician – you must initiate credentialing for the deceased physician’s replacement.

  • Weekend coverage

  • Mid-level or ancillary providers (Certified Registered Nurse Anesthetists, Nurse Practitioners, etc.)

If your situation sounds like one on the prohibitive list, you are probably on the hook to credential the physician. Warning: if you don’t follow these rules correctly, you could land in hot water.

Hot Water?!?

Under the CMPL (Civil Monetary Penalties Law) , you could be penalized up to $50,000 per violation for filing a false claim.

The FCA (False Claims Act) protects the government from false and fraudulent claims when “acting in deliberate ignorance or reckless disregard of the truth.” You could incur up to $11,000 in fines per false claim and even face criminal penalties.

Sources/Links:

CMS Rules for Locum Tenens Billing (pages 72-76)

Civil Monetary Penalties Law (CMPL)

False Claims Act: Civil

False Claims Act: Criminal

Payor Enrollment

 


Susan Ward

About the Author
Susan Ward

At symplr, Susan Ward is the Director of the Payor Enrollment Service product line. With 20+ years’ experience in physician practice management and provider enrollment, Susan is responsible for enrollment operations and relationships with Healthcare Systems, Hospitals, Physician and provider groups focusing on increasing the efficiency of provider onboarding during acquisitions, employment or new practice start up. Her previous experience includes over nine years at Community Health Systems in Franklin, TN, where she served as the Manager of Provider Enrollment, Acquisitions and RHC Enrollment. Her strengths in organizational structure, problem solving and relationship building, as well as her background and knowledge of CMS guidelines, are an asset to Payor Enrollment Services.

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