Written by: Ray Jorgensen, Co-Founder of PMG Credentialing

In the past we have previously discussed Locum Tenens. In short, Locum Tenens is a federal Medicare policy, today called Reciprocal Billing Arrangements, that allows a substitute provider to bill under the NPI of an absent provider. Important to note is this policy applies ONLY to Medicare and ONLY to Part B, fee-for-service claims which means a CMS 1500 or in the ANSI file format, an 837-P.

 We do want to reiterate several important points pertaining to health centers:

• CMS/Medicare is a federal program and their rules/regulations are foundational for other payers. National policy: MCPM Chapter 1, Section 30.2.10

• CMS Requirements

• Regular provider unavailable to provide services

• Patient seeks to receive services from regular provider

• Substitute services not provided > 60 days*

• Billing (regular) provider enters Q5 modifier in 24d of CMS-1500 (837-P)

• Applies to Fee for Service (FFS) via 837-P or 1500 vs. PPS/Encounter Rate via 837-I of UB-04. Health centers bill via the latter making Medicare policy mostly irrelevant.

• Just because a Medicare/CMS policy exists, never assume the same rules/policy applies to state Medicaid or commercial.

• If a payer (ANY governmental or commercial payer) does not have a written policy re: Locum Tenens or Reciprocal Billing, assume no policy exists.

• In general, billing under another provider’s NPI (because the rendering provider is “non-par” or awaiting full third-party payer enrollment) is NEVER pervasively permissible.

• Need written permission/contract language or consider it high-risk activity.

 The reason this conversation is being raised once more is a desire for elevated clarity after hearing an attendee ask a question at NACHC’s Las Vegas-based RevCycle360. I was presenting on a few different topics. When discussing third-party payer enrollment and HRSA credentialing policy, use of locum tenens companies came up as attendees shared their experience. Prior to the discussion I had conveyed the following:

• Companies selling Locum Tenens may mislead health centers. Health Centers CANNOT pay company & bill under “regular” (absent) provider. Health Centers CAN employ/contract (1099) & pay individual but not company.

 What was misconstrued was my saying “no locum tenens” or reciprocal arrangements were really valid for Medicare or any other payer. It was and is a strongly worded message to be cautious about using companies selling “locums” services.

 What I realized was many in the audience were using the term “locums” when in fact the temporary providers were/are “hired” as part or full-time staff. In short, the substitute provider was not using the regular/absent provider’s NPI. Instead, the health center made the substitute provider an employed (W-2 or 1099) staff person. This status legally affords the health center the ability to bill for the provider under an 837-I to obtain PPS or T1015 encounter rate payment. It was not, in fact, a locum tenens or reciprocal arrangement because the provider was actually employed.

 To receive full/optimal payer compensation from all payers (not just PPS/T1015 encounter rate), the substitute providers would obviously need to be fully enrolled with all third-party payers. AND, if these providers were to be perpetual “substitute” staff (when regular staff were absent) full enrollment with all payers is ideal.

 Risk remains if simply paying a staffing company (locums or any other) to send over providers who are not individually employed. Risk mitigation occurs when individual providers are paid as a W-2 or 1099 staff person vs. compensation paid to the staffing entity. In other words, don’t bill under the absent provider’s NPI but instead bill under the substitute’s own NPI or the health center group NPI, the latter for encounter rate payment.

 Hopefully this message is more clear and we welcome any related questions. Shoot me an email at RayJConsulting@gmail.com or engage the experts at PMG Credentialing to manage the whole process. There is always much to learn and sometimes outside assistance is a great way to go.