How to get paid when the physician is away

Tips for covering’ arrangements

Did you know that Medicare permits physicians to bill for services performed by others when they are away from the office? Brett Baker, a third-party payment expert in the American College of Physicians-American Society of Internal Medicine’s (ACP-ASIM) Washington, DC, office, explains how this is done.

PPU: How can providers bill Medicare for services provided to their patients by a physician who is covering while they are away from the office?

Baker: While Medicare typically only pays physicians who actually furnish a service, there is an exception for "covering physician" arrangements. Medicare will pay you for services provided by a covering physician under the following circumstances:

— You can enter into what’s called a "reciprocal billing" arrangement with other physicians to cover each other’s practice on an occasional, as-needed basis.

— You can also have a substitute physician cover your practice as an independent contractor when you are away from the office. This is known as a locum tenens arrangement.

PPU: What are the differences the fine print in the two kinds of arrangements?

Baker: The rules are similar, but there are some important differences. For instance, a reciprocal billing arrangement is typically an agreement among physicians that one will cover the other’s practice when the regular physician is absent. Reciprocal billing arrangements are often informal, and Medicare does not require them to be in writing. No money changes hands, and the regular physician compensates the covering physician by reciprocating in the future under similar circumstances.

Physicians can develop reciprocal billing arrangements with more than one physician. For instance, such arrangements often include physicians who occasionally cover for their colleagues during extended office hours and who cover for colleagues who are on call on the weekend.

The coverage period for reciprocal arrangements is usually pretty short. However, Medicare says they last up to 60 days if certain criteria are met.

PPU: What about locum tenens arrangements?

Baker: Locum tenens is different in that the substitute physician generally does not maintain a practice, instead traveling from area to area as needed. The regular physician typically pays the substitute physician a fixed per diem amount, with the substitute physician working as an independent contractor, not an employee.

PPU: Are there any specific billing requirements for reciprocal billing arrangements?

Baker: Medicare will only honor reciprocal billing arrangements if the:

— regular physician is unavailable to provide the services;

— beneficiary has arranged or seeks to receive the services from the regular physician;

— substitute physician does not provide the services to the beneficiary over a continuous period of longer than 60 days;

— regular physician identifies the services as substitute physician services.

PPU: What about length of coverage?

Baker: Coverage starts the first day the substitute physician provides Medicare Part B services to the regular physician’s patients and extends to the last day on which the substitute physician provides services before the regular physician returns to work, provided it is under the 60-day limit.

PPU: Can physicians in the same group practice have a reciprocal billing arrangement with each other?

Baker: Reciprocal billing arrangement rules do not apply to substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group.

As a result, physicians in medical practices that bill as groups do not need to maintain reciprocal billing arrangements with other members of their group.

PPU: What are the requirements for a locum tenens arrangement?

Baker: Medicare recognizes that physicians often retain a substitute physician to take over their professional practices while they are absent for such reasons as illness, vacation, continuing medical education, and pregnancy. Medicare also recognizes that locum tenens arrangements will pay the regular physician for services provided by the substitute provider if the:

— regular physician is unavailable to provide the services;

— beneficiary has arranged or seeks to receive the services from the regular physician;

— regular physician pays the locum tenens physician on a per diem or a fee-for-service basis;

locum tenens physician does not provide services to beneficiaries over a continuous period of more than 60 days;

— regular physician identifies the locum tenens physician on claims submitted for the services provided by the locum tenens physician.

PPU: What about billing?

Baker: When billing under either a reciprocal or locum tenens arrangement, enter the substituting physician’s unique physician identification number (UPIN) in field 23 of the HCFA 1500 form. If the billing physician is a solo practitioner, the physician needs to list his or her UPIN in field 33. But if the physician works in a group practice, list the UPIN in field 24k.