Locum Tenens: Rules and FAQs

The AdvantEdge Compliance Office would like to remind everyone of the Medicare guidelines when contracting with a temporary substitute physician, commonly known as a ‘locum tenens’. The FAQ’s below are from several CMS MAC’s and answer questions commonly posed by physicians and administrators.

The Basics:

A physician may hire a substitute physician to take over his/her practice when they are absent for reasons such as illness, pregnancy, vacation or continuing medical education. The substitute physician, known as a ‘locum tenens’, generally does not have their own practice and many move from area to area as needed.

  • The regular physician generally pays the substitute physician a fixed per diem amount.
  • The substitute physician’s status is that of independent contractor, rather than employee, and his/her services are not restricted to the contracting physician’s office.
  • Services of non-physician practitioners (e.g., CRNAs, NPs and PAs) may not be billed under the Locum Tenens or Reciprocal Billing reassignment exceptions. Locum provisions apply only to physicians.
  • The ‘regular’ physician cannot be submitting claims (providing services in another facility) while a locum tenens is ‘standing in’ for the regular physician. The regular physician is presumed (required) to be ‘unavailable’. The regular physician, who is away, cannot be practicing somewhere else while having a locum covering for him/her at their primary location.

FAQ’s

  1. The Medical Group has a signed contract and has HIRED a new physician to replace one who has left. Can the newly HIRED physician act as a locum for a physician who recently left, while the group awaits enrollment for the new hire?
    • No, a locum tenens is NOT an employee; rather, their status must be that of an independent contractor.
  1. Our practice is in the process of enrolling Dr. X. While awaiting the credentialing process, can we use Dr. X as a locum tenens for a physician who is on vacation?
    • No, in such a case, the locum tenens concept is not applicable. Locum tenens is only appropriate for absent physicians who retain a substitute physician for no longer than 60 continuous calendar days.
  1. How can a group that loses a physician use locum tenens while recruiting a new physician?
    • The group can contract with a locum tenens physician and pay him/her a fixed amount per diem. The payment to the contracted physician is considered to be paid by the regular physician (the group pays the locum tenens physician on behalf of the regular physician.)[1] The group may bill for the contracted physician for up to 60 continuous days. The claim contains a modifier Q6. The claim must contain both the group NPI and the regular physician NPI. The group must keep on file a record of each service provided by the substitute physician and make this record available to any MAC upon request.
  1. If a physician terminates and leaves our group and we contract with a locum tenens physician, what are the guidelines for this situation? When do we have to notify Medicare of the change?
    • If a physician terminates and leaves your group, a contracted locum tenens physician can see the exited physician’s patients for up to a 60-day continuous period, beginning with the first day the locum physician sees one of the exited physician’s patients.
      • IMPORTANT NOTE: CMS requires that providers report certain “reportable events” within specific timeframes. You must report a change of ownership or control, including any revocation or suspension of a Federal or State license within 30 days of a reportable event. Also, the group has up to 90 days to notify Provider Enrollment that the physician left the group. To learn more, refer to the CMS Provider Enrollment Fact Sheet titled “The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers.”
  1. In replacing a physician who has left the practice, is there a requirement that the locum start within a certain time period from the departure date of the regular physician?
    • No, but the eligibility period for the locum tenens physician substitution may be affected because the practice is required to notify Provider Enrollment of the change in practice status (physician left practice) within 90 days.
  1. Our regular physician has been terminated from the group due to suspected illegal activities which will most likely affect his medical license in the near future. Should I contract with a locum tenens to provide services while we search for a new provider?
    • If the groups ‘regular’ physician is not in good standing, it is not advisable to use the exited NPI’s number to continue to bill for services provided by a locum. These services will most likely come into question, with possible future retraction of payment.
  1. Our regular physician will need to be absent for an extended period of time. Can we arrange for the same locum tenens physician to see the regular physician’s patients during the extended absence?
    • The period for which a single locum tenens physician may substitute cannot be more than 60 continuous days. The 60-day period begins the first day the locum tenens physician provides services for Medicare patients of the regular physician. An exception to this 60-day rule is for regular physicians who are called to active duty in the armed forces. In that case, the time is unlimited.
  1. Our organization operates multiple sites throughout the state and often employs locum tenens to fill in for regular physicians. Can we bill for the locum tenens under another provider’s NPI number if that provider is not located (regularly scheduled) at the site where the locum tenens is practicing?
    • No, the regular physician must be temporarily unavailable. Because there is no “regular physician” who is temporarily unavailable, the situation would not permit billing under the locum tenens rule. Moreover, a physician who does not work at the site in question could not be considered the regular physician in the context of the locums rule because that physician is not “unavailable” for one of the permissible reasons.
  1. Can a locum tenens physician see new patients?
    • Yes, as long as the patient requested or was seeking services from the regular physician.
  1. Does locum tenens apply to a deceased provider?
    • No, Medicare only permits payment for services furnished prior to a physician’s death. When a physician becomes deceased, his/her billing number, NPI and enrollment are deactivated and cannot be used after the date the physician passes away. Therefore, a locum tenens arrangement would not be permitted.
  1. Is the 60-day period cumulative or consecutive?
    • The 60-day continuous day period begins the first day the locum tenens physician provides services for Medicare patients of the regular physician. This period continues for up to 60 calendar days, with no breaks, even if the locum tenens does not see patients on some of those days. In situations where the regular physician is going to be absent for more than 60 days, an alternative plan for physician coverage and patient care should be created. An exception to the 60-day continuous rule is for regular physicians who are called to active duty in the armed forces. This time is unlimited.
  1. Our physician will be out for 60 continuous calendar days, beginning June 1st. Will Medicare allow two different locum tenens physicians to substitute for the same regular physician?
    • A regular physician may use more than one locum tenens to substitute for his/her absence during the same 60-day period; however, the substitutes cannot act on the same day. Assuming that each locum tenens physician is providing services within his/her respective 60-day continuous period, locum tenens physician Dr. A can provide services, for example, on Monday, Wednesday, and Fridays, and locum tenens Dr. B can provide services on Tuesday, and Thursday, but Dr. A and Dr. B cannot be scheduled as the substitute for the regular physician on the same day.
  1. Does the locum physician have to be of the same specialty as the physician who is absent?
    • No.
  1. Our practice has a high volume and our physicians are unable to see all of the patients. Can we use a locum physician and bill under the provider who is out for the day if it is their regular day off?
    • No, in such a case, the physician is a regularly scheduled physician and the locum tenens concept is not applicable.
  1. We had two providers leave our specialty group. We are using two locums to cover as we recruit replacements. Can we assign a locum to an absent provider and always bill their services under this provider, or do we have to bill the provider that was ‘requested’? In some cases, they are new patients.
    • A locum tenens physician is the substitute for a physician who is absent. Once entered into, the locum tenens physician should not substitute for a different absent physician. It is the expectation that the locum tenens will see only those patients that requested the regular physician for which the locum is substituting. This would include a new patient.
  1. If a practice wants to “try out” a doctor they are considering hiring, can the practice bill under locum tenens?
    • No, this does not meet the CMS definition for locum tenens.
  1. If a practice just “needs help” to get through a busy period, i.e. a doctor is ill and working part time, can the practice hire a locum to bill under the part time doctor’s name/number?
    • No, locum tenens is only applicable when the locum physician is substituting for the regular physician for those periods defined in the Internet Only Manual (IOM). It does not apply when the regular physician is working part time due to an illness.

Remember, to the extent that services billed were discovered to have been submitted incorrectly, the entity should do a voluntary disclosure and refund monies improperly paid and received, in compliance with the reverse false claims provision of the False Claims Act. Failure to do so would result in those claims being deemed false claims, and FCA damages and penalties would apply.

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CMS guidelines are found in the CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 30.2.11.

[1] This works until the physician who left the group is linked to a new group, but in no case longer than 60 continuous days.