Compliance Category
By Delly Parham, CPC
Using locum tenens physicians to fill in for regular physicians may cost your practice instead of helping it if you don’t understand how to bill for their services. To ensure you get paid and stay in compliance, you must adhere to Medicare and commercial payer guidelines.
Practices usually use locum tenens (Latin for “lieutenant”) physicians when the regular physician is absent because of vacation, illness, childbirth, business, education, active duty, or having left the practice. The advantages of hiring a locum tenens physician versus using a physician in the same practice or in the same area are that it:
- Retains the regular physician’s existing patients
- Introduces new patients to the practice
- Maintains the patient level
- Keeps revenue with the regular physician
Most practices using the services of a locum tenens go through a recruiting agency, such as Comp Health. These companies handle the licensing requirements, professional liability insurance, and screening of the locum tenens, taking the liability and burden off practices. The practice or group pays the recruiting agency, and the agency pays the locum tenens physician. If your practice chooses to hire the locum tenens directly, you must:
- Check your state licensing laws for licensing requirements. Most – if not all – states require physicians be licensed in that state.
- Check with your professional liability insurance carrier.
- Make sure the locum tenens is in good standing and get his or her professional liability insurance certificate, verifying it covers the services the locum tenens will be performing for the regular physician.
Whether you use a recruiting agency or hire the locum tenens physician directly, the practice must:
- Train staff with information about locum tenens physician to retain patients with the regular physician and give them incentive to see locum tenens without fear, for example:
- The locum tenens is temporary and will only see them once or for a short period of time.
- The locum tenens’ experience and expertise as a physician.
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. The time is unlimited. See Social Security Act at section 1842(b)(6)(D.)
The regular physician:
- Must schedule appointments under his or her schedule.
- Is the only physician who can break the locum tenens’ 60-day period.
- May re-set the 60-day period by returning to practice and see patients only one day after the initial 60-days and use the same locum tenens.
- Must bill for the services of the locum tenens.
- Must put his or her NPI number on all claims filed.
- May use more than one locum tenens to substitute for absences during the 60-day period.
- May reimburse the locum tenens a fixed amount per diem or similar fee for time.
- Must keep a record of each service furnished by the locum tenens physician and the NPI.
A locum tenens physician:
- Fills in for the regular physician for 60 continuous calendar days.
- Can substitute only if the regular physician is absent for any of the reasons above.
- Cannot substitute more than 60 continuous calendar days, unless there is a break in the 60-day by the regular physician.
- Cannot re-set the 60-day clock by taking a day off.
- Generally does not have a practice of his or her own and moves from area to area as needed.
- Is usually an independent contractor of the regular physician or group rather than an employee.
- Does not have to be enrolled in the Medicare program to see Medicare patients
- Cannot be a non-physician practitioner (e.g., NPs, CRNAs, PAs).
- Cannot bill Medicare for services within the 60-day continuous period in his or her name or NPI.
The regular physician bills and receives payment from Medicare and other payers who follow Medicare’s guidelines for the locum tenens physician’s services as though the regular physician performs the services. The regular physician must put the regular physician NPI in box 24J and his or her name in box 31 of CMS 1500 and the regular physician or group name and NPI in box 33 of the CMS 1500. Other Medicare rules include:
- Use the name and NPI of the regular physician or group.
- Use modifier Q6 after the procedure code (Q6 identifies services by locum tenens physician).
- If the only service a locum tenens physician performs is post-operative for an operation within a global period, it cannot be billed with Q6 modifier because the regular physician is paid a global fee, and it is not necessary to include the service on the claim.
- If a regular physician requires that the locum tenens physician provides services for longer than 60 continuous days without a break, the locum tenens physician must enroll with the practice.
Other payers have different rules. TRICARE requires that non-contracted locum tenens physicians complete a certificate or other document to be linked to the regular physician or group tax identification number. Some Medicaid programs (e.g., Florida Medicaid) require the locum tenens physician bill under his or her own name and NPI. Blue Cross Blue Shield adheres to the guidelines of Section 125b of the Social Security Act. (BCBS Manual for Physicians and Providers, May 2010).
Sources:
Medicare Claims Processing manual, Chapter 1, Section 30:2.11, www.cms.hhs.gov/manuals/downloads/clm104
www.cms.hhs.gov/transmittals/dowloads/R1486cp
April 19th, 2013
By Robert A. Pelaia, Esq., CPC, CPCO
It’s foolish to ignore the signs that set off Office of Inspector (OIG) radar. Look around your work environment. If an OIG investigator walked into your office right now, what would he or she see (or not see) that shows compliance is not taken seriously in your practice?
Here are 10 telltale signs, in no particular order, to show investigators that they should take a second look at your compliance activities:
1. Patient Records are in Plain Sight: This is a big Health Insurance Portability and Accountability Act (HIPAA), red flag. It shows that you have no regards for confidentiality of patient information.
2. You Have No Compliance Contact: Your office should designate someone to be in charge of compliance activities. Whether you have an individual or group of individuals responsible for compliance, it’s important to have a “go-to” person for compliance issues.
3. Coding Books Are Outdated: Coders must keep on top of all the newest coding changes and if coders are using outdated coding books or software, that’s a compliance risk. It’s good to keep old coding books around as a historical reference; however, never code from outdated books.
4. Free Limousine Transportation Offered to Medicaid Patients: Section 1128A(a)(5) of the Social Security Act, enacted as part of HIPAA, imposes significant civil money penalties on providers who offer free gifts or services to Medicare or Medicaid beneficiaries that can influence the beneficiary to order items or services from the provider.
5. Coder “Cheat Sheets” Are Posted: It’s alright for coders to have code lists to help work more efficiently; however, an OIG investigator might have a significant problem if the “cheat sheet” only reflects high level codes. For example, if you are listing new patient evaluation and management (E/M) codes on your “cheat sheet,” make sure you list all five levels of new patient E/M codes, not just ones that pay the most money.
6. Memos Posted Instructing Coders to Change Diagnosis Codes: It’s okay to have a list of “covered” diagnoses, but it is not appropriate for the coder to change the diagnosis to one not supported in the medical record. Posted memos telling coders to use particular codes only when submitted with certain “covered” diagnoses and to change to another code if the “wrong” diagnosis is submitted is a red flag to OIG investigators.
7. Coders Get Bonuses when Revenue Increases: The government will closely scrutinize a bonus structure paid to a coder based on increases in revenue because the arrangement might be an incentive for an unscrupulous coder to “up-code.” Coding is complex enough without muddying the water with bonus structures tied to revenue. The less risky route is to base the incentive on productivity, timeliness, or accuracy, rather than revenue.
8. Dusty Compliance Manual: A compliance manual should not sit on the bookshelf, as it should be a useful and comprehensive reference tool used often and updated periodically.
9. Employee Complaints with No Follow-up: An organization that receives complaints or uncovers evidence of improper billing must demonstrate it responded appropriately to the situation, including taking necessary steps to prevent further similar offenses. If the organization’s management personnel fail to investigate employee complaints promptly, this questions the effectiveness of the program.
10. Not Employing “Certified” Coders: You can tell a lot about a health care employer by the company it keeps—it is true that you get what you pay for. Employers who hire certified coders are employers who maintain higher standards, value integrity, and understand that compliance activities are a requirement.
Disclaimer: Information published in this article is the personal views of the author and is not intended to be, nor should it be considered, legal advice. Readers should consult with an attorney to discuss specific situations in further detail.
April 16th, 2013
Intermountain Health Care Inc., the largest health system in Utah, agreed to pay the United States $25.5 million to settle Stark Statute and False Claims Act violation claims. The allegations are for ”engaging in improper financial relationships with referring physicians,” according to a U.S. Department of Justice (DOJ) Press Release on April 3.
The alleged relationships involved 209 physicians in violation of Stark Statute and included employment agreements where:
- Physicians received bonuses that improperly took into account the value of some of their patient referrals; and
- Office leases and compensation arrangements between Intermountain and referring physicians that violated other requirements of the Stark Statute.
Intermountain Discloses Itself
When Intermountain discovered their wrong doing, it disclosed the issues to the government. The OIG’s special agent in charge of Utah, Gerald Roy said, “I applaud Intermountain for recognizing their liability and coming forward to self-disclose these violations.”
Intermountain is known for a reputation of quality and efficiency of care. In fact, Intermountain’s reputation received accolades from President Barack Obama in a 2009 speech, according to ModernHealthcare.com‘s article, ”Intermountain to pay $25.5 million to settle Stark case.” Obama said in the speech, “We have to ask why places like … Intermountain Health in Salt Lake City … can offer high-quality care at costs well below average, but other places in America can’t. We need to identify the best practices across the country, learn from the success, and replicate that success elsewhere.”
There are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top 3:
1. Incorrect and/or incomplete patient identifier information (e.g., name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid)
Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state-issued identification (passport, drivers license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.
2. Coverage terminated
Solution: Verify insurance benefits prior to services being rendered.
3. Services non-covered/Require prior authorization or precertification
Solution: Here again, you should contact the patient’s insurance and confirm coverage prior to services being rendered. You’ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.
Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services (CMS), announced there will be no delay to implementation for ICD-10-CM and PCS, which is scheduled October 1, 2014. She then encouraged everyone in the industry to work diligently toward a successful transition.
Tavenner made the statement at the annual Health Information Management Systems Society (HIMSS) conference, a year after she announced a 90-day comment period to determine if and how long a delay would be. The comments at that time ranged from killing ICD-10 completely to making no change from the originally planned date of 2013. Ultimately, the implementation was postponed by a year. Many providers and payers are using the extra year to better prepare.
Several organizations hoped Tavenner might announce another postponement at the HIMSS gathering, and some still advocated shelving the code set, but it looks like implementation is a done deal.
March 21st, 2013
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