Everyone needs a break, and sometimes we need a temporary replacement when unexpected circumstances arise. Often, this requires temporarily hiring another doctor. In healthcare, this is usually referred to as “locum tenens”, a Latin phrase meaning “to hold the place of,”. While hiring a temporary doctor for your practice can be very beneficial, there are some rules you must be aware of for both vision and medical insurance plans, as well as state law.
Medical Plans and Relief Doctors
Medical payers also allow for this, and Medicare has specific rules that you can look to for guidance.
Medicare classifies relief doctor arrangements in 2 ways:
- Reciprocal billing – an agreement between providers to cover each other’s practice when the other is absent. The regular physician may bill for the substitute’s services under their own NPI using modifier Q5
- Fee for Time – the regular physician pays the substitute a fixed amount (e.g., per diem) and bills under their own NPI, using modifier Q6 to indicate the substitute’s services.
Reciprocal Billing Under Medical Plans
Medicare policy states that a patient’s regular physician may submit claims, and may receive payment for covered services (including emergency visits and related services) for services provided by a substitute physician on an occasional reciprocal basis, if:
- The regular physician is unavailable to provide the services.
- The Medicare patient arranges or seeks services from the regular physician.
- The services must not be provided by the second physician over a continuous period of more than 60 days (except in active-duty cases).
- The regular physician identifies the services as substitute physician services by reporting the Q5 modifier
Covered services include not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as “incident to” the physician’s services.
Fee-For-Time Compensation Arrangements Under Medical Plans (formerly locum tenens)
Medicare states that a patient’s regular provider may submit the claim and receive payment for covered services of a substitute physician, if:
- The regular physician is unavailable to provide the services.
- The Medicare beneficiary has arranged or seeks to receive the services from the regular physician.
- The regular physician pays the substitute for his/her services on a per diem or similar fee-for-time basis.
- The services must not be provided by the second physician over a continuous period of more than 60 days (except in active-duty cases).
- The regular physician indicates that the services were provided by a substitute physician under a fee-for-time compensation arrangement by entering modifier Q6 after the procedure code.
Generally, most medical plans model their policies after Medicare, but be sure to check with each payer to ensure you are using the correct rules and modifiers.
Vision Plans and Locum Tenens
Vision plans generally allow this too, and payers like Eyemed and VSP actually have written policy on this. VSP policy states:
- When using a fill-in doctor, such doctor shall be a VSP-credentialed doctor in good standing.
- If unable to arrange for a VSP credentialed doctor to fill-in the following applies:
- If the fill-in doctor(s) is to fill-in for a period of 10 days or less in a calendar year, VSP does not need to be notified and the use of a non-VSP credentialed provider shall be permitted.
- If the fill-in doctor(s) is to fill-in for a period of 11 days but not more than 60 days in a calendar year, VSP reserves the right to either approve or deny the fill-in doctor(s). The network provider shall contact VSP at least 10 calendar days in advance of a planned absence with the fill-in doctor’s name, degree, license number and NPI number.
VSP will verify things like the provider’s state license, malpractice insurance, malpractice claims, and preclusion lists.
VSP also allows for up to 60 days of locum tenens coverage in an emergency situation for up to 10 days before approval but requires the provider to contact VSP as soon as possible and provide name, degree, license number and NPI and information related to the emergency situation.
Submitting Vision Claims For Locum Tenens Providers
VSP policy states that claims should be submitted under the employer’s NPI and Tax ID number and should include the fill-in provider’s NPI or SSN in box 19 “Reserved for Local Use” and a modifier for each line. VSP specifies use of modifier Q5 (even though this is the reciprocal billing modifier).
Similar rules will be found with other vision plans: notify the vision plan, provide the information on the fill-in provider, and use the appropriate modifier as established by the vision plan (be sure to check the provider manual for the vision plan for specific rules and modifiers).
Additional considerations
- Licensing: The substitute provider must hold a valid, unrestricted license to practice in the state where they will be working.
- Scope of Practice: The substitute provider is generally limited to practicing within the scope of practice allowed for optometrists in the specific state where they hold a license.
- Malpractice Insurance: The provider should ensure that the substitute provider has malpractice insurance.
If you have any questions, feel free to contact us at info@PracticePerformancePartners.com