Adding a Provider - Understanding Locum Tenens

Adding a Provider - Understanding Locum Tenens
What exactly is locum tenens?  An online dictionary defines it as, “one filling an office for a time or temporarily taking the place of another -- used especially of a doctor or clergyman.”  The origins of the concept date back to the 1600s and the Medieval Latin phrase “locum ten ē ns,” which means “holding the place.”  It seems there is an unlimited number of advertisements on the Internet for locum coverage of medical professionals.  Locum tenens as a model for the billing of services creates challenges of which you should be aware.
When a practice is in need of temporary coverage for a provider who is ill or has left a practice, Medicare allows locum tenens to become a billing concept.  Use of this code allows a practice to bill for a substitute provider’s services using the Q6 modifier on the claim.  The scenarios under which this is allowed are well-defined in the Medicare Carriers Manual in Chapter 1, Publication 100-04.  Medicare payment policy indicates that locum tenens is permitted for physician services only.  You cannot use the concept for services provided by non-physician practitioners (NPP).

Non-Medicare insurance carriers employ different rules for billing when services are provided by locum tenens physicians.  While I have not personally found any carriers that allow NPPs to use the concept, many also do not allow for the payment of physicians providing locum tenens services.  Some carriers go as far as requiring some level of credentialing of the substitute physician.    As a result, locum tenens does not apply.  These carriers require billing of services under the temporary physician’s own NPI number.

An example of a potential pitfall is seen when a claim is submitted to a non-Medicare carrier that does not allow payment for locum tenens services.  The insurance company does not recognize the Q6 modifier and at first ignores the code listed on the claim form.  As a result, the claim passes through their computers appearing as a claim submitted by an off-duty physician.  The insurance company thinks your regular physician provided the service and the services are subsequently paid for.  However, when the chart is audited and it is discovered the name of the provider on the claim form is not the same as the one who provided the service and signed the patient’s note, the claim is denied and funds recovered.
The lesson here is if your practice is adding a new provider, be sure to know the policies of your insurance carriers, including Medicare.  This will prevent you from submitting claims where the insurance carrier could misidentify the physician provider.  It will also help prevent erroneously billing locum tenens services provided by NPPs.

Stay True to Why You Pursued Medicine.