Without a doubt, there are few CHC topics which seem to generate as much confusion as the use of “locum tenens.” By definition, locum tenens is used to define a provider who temporarily fills in for a vacancy, vacation, or extended leave for another provider. This definition is recognized primarily by Medicare (Section 30.2.11 https://www.cms.gov/manuals/downloads/clm104c01.pdf) and requires the claim to be billed using the NPI of the provider who is absent while appending a “Q6” modifier on all HCPCS (e.g., CPT) codes. Medicare is perhaps the only payer with totally consistent use/definition of this term. Yet, we see CHCs use a VERY liberal interpretation of “locums” (e.g., billing under a medical directors’ NPI for new staff who are not yet credentialed or “on call”) for many commercial payers and, even more frighteningly, for Medicaid (straight ‘Caid and managed Medicaid). Remember, commercial and Medicaid payers use Medicare rules/regulations as a foundation but rarely follow them exactly.
Any CHC attempting to utilize a locum tenens situation needs IN WRITING from each major payer whether A. they recognize locum tenens and B. if so, what billing requirements must be met/followed. Aside from even inadvertent misuse falling under the definition of (at best) an “abusive coding practice or (at worst) a “fraudulent claim,” providers whose NPIs are used (much of the time unbeknownst to them) are at risk for being party to this false claim filing. PMG recommends all clinicians request (if not contractually obligate) their employer-CHC to provide reports (from the CHC’s practice management product) which clearly demonstrates which claims/services were billed under his/her unique NPI. As an employed provider, you have a right to know.
Another point worthy of mention, locum tenens works ONLY for Medicare Part B. Medicare Part A (for a CHC what we call it “encounter rate payment”) simply requires a 1099 or W-2 relationship with a “core provider;” i.e., the core provider does NOT have to be credentialed with Medicare to receive encounter rate payment. HOWEVER, most state Medicaid and commercial plans do require each unique provider to be credentialed so claims may be submitted under his/her unique PARTICIPATING NPI. This is not optional.
Certainly we recognize that billing/finance may often be the last place to find out that a new provider (or even medical director) is hired. We just received notice from one of our clients that a new Medical Director starts Monday… we were told the preceding Wednesday!! Even if this provider is FULLY credentialed with all the local payers before coming on board (and this is rare), just reassigning their NPI for each payer is at least a 30 day process… and that is if there no issues.
In the end, know the rules and follow them. PMG’s basic recommended rule… each core provider should have his/her own NPI and it should be “participating” (i.e., uniquely credentialed) with all payers that require CMS-1500 (ANSI 837P) claims. If they have an NPI, USE IT!?!