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Locum Tenens and Your Practice

locum tenens

Recently one of our clients asked us if they could use locum tenens while they were on vacation.  As summertime approaches, this question may be on everyone’s mind, so it seems like a good time to review acceptable and unacceptable uses of a locum tenens.  After all you don’t want to arrange for coverage of your practice and then not get reimbursed for the services rendered.

For Medicare eligibility and reimbursement, specific criteria must be met for a legitimate locum tenens, or fee-for-time compensation arrangement:

  • The substitute provider can only bill under the regular provider’s National Provider Identifier, or NPI, number for 60 continuous calendar days, unless the regular physician was called to active military duty.
  • The patients must seek the services of the regular physician.
  • Claims submitted to Medicare must use the modifier “Q6,” to indicate the use of a locum tenens.
  • The substitute physician must not be an employee, but an independent contractor.
  • The substitute physician must be paid on a per diem or similar time basis.

What Are Acceptable Uses of a Locum Tenens?

Examples of acceptable uses for a fee-for-time compensation arrangement include the following scenarios:

  • A physician takes a leave or goes on vacation. During that time, another physician sees that physician’s patients. Those visits can be billed to Medicare under the regular physician’s name, and Medicare will reimburse the regular physician as if she performed the services.
  • A physician terminates from the group. While the group tries to recruit a replacement, a substitute physician covers that physician’s caseload for up to 60 days.
  • Two locum tenens providers cover the panel of a physician on leave for 60 days, alternating the weeks they work.

What Are Unacceptable Uses of a Locum Tenens?

For Medicare purposes, the following are unacceptable uses of a fee-for-time compensation arrangement:

  • If a physician dies, no one can bill under that physician’s name.
  • Locum tenens arrangements for Medicare do not include nurse practitioners, physician assistants or any other provider type besides physician and physical therapist (in certain geographies or region). However, they do not need to be of the same specialty.
  • A newly hired physician cannot bill as a locum tenens provider while pending Medicare enrollment; employees do not qualify.
  • You are expanding your practice and need additional providers. A fee-for-time arrangement would not qualify, since there is no regular physician to substitute for.
  • The regular physician cannot provide services elsewhere while a substitute physician also is billing under her credentials; the regular physician cannot be available to work.

The above rules apply to the Medicare program. Different insurance plans can have their own rules regarding the allowed use of a substitute physician, but most will follow Medicare.  However, it is always a good thing to check with each carrier.

There is a Cure to Medical Necessity Denials

Did you know that claims for services that do not meet the requirements of medical necessity are getting denied instantly? Payers are increasingly more focused on the issue of medical necessity.

Medical necessity is difficult to define, since there are so many interpretations and they vary from payer to payer. Most typically incorporate the idea that healthcare services must be “reasonable and necessary” or “appropriate” based on the patient’s condition and current standards of care.

DENIALS, RECOUPMENTS, PENALTIES

Sadly, the decision as to whether services are medically necessary are made by someone who has never seen the patient. Most payers use automation to review and deny claims. These are called claim edits. The edits ensure that payment is made based on a specific diagnosis related to specific procedure codes. Diagnosis codes identify the medical necessity of services provided.

CMS has the power, under the Social Security Act, to determine whether each situation is reasonable and necessary. Even if it is that they later determine do not meet medical necessity the scope of the service can be limited.

To make matters worse, if a carrier pays for services that they later determine to no meet medical necessity, they will recoup those payments. They can demand a refund or just deduct the amount directly from a future reimbursement check. They also have the right to charge interest.

If they determine that the provider has a pattern of billing for medically unnecessary services, the provider may face monetary penalties, exclusion from the Medicare program, and criminal prosecution.

HOW TO AVOID MEDICAL NECESSITY DENIALS

According to the American Academy of Professional Coders (AAPC), there are 8 key steps to follow:

  1. List the principal diagnosis, condition, problem, or other reason for the medical service or procedure.
  2. Assign the code to the highest level of specificity.
  3. For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis); a clerical error could permanently tag a patient with a condition that does not exist. Code symptoms, if no definitive diagnosis is yet determined, instead of using rule-out statements.
  4. Be specific in describing the patient’s condition, illness, or disease.
  5. Distinguish between acute and chronic conditions, when appropriate.
  6. Identify the acute condition of an emergency situation; e.g., coma, loss of consciousness, or hemorrhage.
  7. Identify chronic complaints, or secondary diagnoses, only when treatment is provided or when they impact the overall management of the patient’s care.
  8. Identify how injuries occur.

If your claim is still denied your billing company should appeal the denial. This will require additional work on their part. It takes a lot of work and time to appeal a denied claim. It is tedious work and billers don’t like doing it. It is hard-earned money and one of the many ways a good billing service earns its money. It also requires that the medical note supports the coding. If the appeal is handled correctly there is a good chance the denial will be reversed, and the claim will be paid.

Who is the MVP in your Office?

Every person, every task, every patient is important, but the front desk is the quarterback for the office. They set everything in motion. They get the nod as the MVP.

Scheduling the patient is the easy part but everything after that is tricky at best and of paramount importance. Before the patient comes in benefits need to be confirmed, referrals and pre-authorizations must be obtained and recorded.

Once the patient presents at the office there is a whole new set of responsibilities and must be done with laser accuracy. It doesn’t matter how good the nursing staff is or how good the doctor is because if the front desk didn’t do their job then that visit won’t get paid.

Maybe you think registering patients is easy, but it isn’t. This requires that all the patient’s information and the responsible party’s information be recorded accurately. It isn’t enough to just ask if anything has changed you must confirm all demographics and then make sure that the current insurance card is scanned into the record. People change jobs, move, and get married and companies change insurance plans and so it is important to check every time. Also, the patient’s name and the responsible party’s name, if any must be recorded in the chart exactly as it appears on the insurance card. If the front desk isn’t looking at that card and scanning it into the record, then that is a fumble and will cost you.

As the patient is checked in or as they schedule their follow-up visit take the time to collect copays and deductibles. This is critical during the first part of every year since patients haven’t met their deductibles yet. If your front desk staff is asking for payment at the time of service, then you have a very valuable team player. Lots of people are uncomfortable doing this so make sure your front desk staff has the skill set to ask for payment. Your patients won’t get as many billing statements and your practice will be rewarded with improved cash flow.

It’s true – it takes everyone on the team to make a practice successful and maybe you are lucky and have several MVPs but make sure one of the MVPs is at your front desk!

Billing and Collections is a Team Effort!

Rub employees the right wayIf you want your billing and collections to be as smooth and effective as possible, it must be a team effort.  It can’t be up to just a couple of people and it definitely can’t be a blame game.

Practices are overwhelmed with phone calls, paperwork, pre-authorizations, and patient care.  Sometimes the ‘paper’ things can fall through the cracks.  It is these things that end up snowballing and result in more work, frantic calls and denied claims.

Here are some tips that will help smooth out the process.  They may seem insignificant or deemed to be more trouble than they are worth.  But, in the long run, if everyone on the team does their part, it means less clean-up work, less stress, and faster payments.

The collection process starts BEFORE the patient shows up for their appointment.

  1. If the patient is new to the practice send a welcome packet with all of the paperwork that they need to complete.  Sending it before the appointment helps to ensure they will have all of the correct information.
  2. If they are established patients then remind them to bring their current insurance card.
  3. On the day of the visit, ask to see a copy of the patient’s insurance card.  Too many times this step is either omitted or the staff will just ask if anything has changed.  Most patients will automatically say no simply because they don’t remember.  Insurance plans change more frequently these days, so it is best to verify and update all information at every visit.
  4. Make sure that the name on the insurance card matches exactly to what is entered in your practice management system.  Mis-spellings, missing middle initials, and typographical errors will all result in denied claims.
  5. Collect all outstanding patient balances before the patient goes into the exam room.
  6. Make it as easy as possible for patients to pay their deductibles, copay or self-pay payments.  Allow payments via credit cards, patient portals, mobile devices, and paper checks.
  7. Train select employees to set up payment plans for those patients that can’t pay their portion of the bill in full.  Make sure your back office or billing company knows of these payment plans so they can track compliance.
  8. The billing staff or company can’t bill and collect if charges aren’t submitted.  Make sure that charges are submitted daily.  There should be a check and balance to ensure that a charge was submitted for every patient that had an appointment that day.
  9. Make sure that coding is accurate.  Do you have the correct modifier?  Are the number of units correct?
  10. Make sure the pre-authorization/referral matches the service and the date of service exactly.  Make sure the information is noted on the claim.

When everyone on the team takes their part of the billing and collection process seriously things will go much smoother.  The practice will see an increase in revenue and the staff won’t struggle with clean-up work.  That is a win for everyone.

8 Ways to Play the Prior Authorization Game

prior authorization
The prior authorization game is an art, not a science.

There is nothing more frustrating to physicians than knowing a patient needs a certain diagnostic test or medication and having them not be able to get it because their health insurance company won’t cover it. All too often, many services require prior authorization.It wouldn’t be so bad if the insurance companies made the guidelines they use to make these determinations readily apparent to those practicing medicine. However, these guidelines are created by the insurance company.  The guidelines are unavailable to treating clinicians, and often they use decades-old recommendations. We are often left to predict the insurance company’s decision.  The carrier’s main goal is cost containment rather than evidence-based medicine.

Many of us feel that it is like playing an epic game where we try to give our best care to our patients, while the insurance companies deny as many tests as possible to increase their profits. The loser of this game is not the one who was able to get the least amount of services covered or earned the least money. Rather, it is the patient: delayed diagnoses/treatment; denied tests; or forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.

How can this prior-authorization game be played for better odds of winning?

– Whoever does the prior authorization needs to have the progress notes in front of them. They will be asked clinical data and it should be at their fingertips.

– Know what needs to be documented in the chart. For example, I had a patient with knee pain who I suspected a torn ligament in the knee. When talking to the rep to get prior-authorization for an MRI, I told her the patient had a positive drawer sign. She never heard of this before and because I didn’t record the results of the Lachman test in the note, she could not approve the MRI. She didn’t know what this test was (I asked) either, but it was a checkmark on her decision tree. I record them all.

– Learn what is needed to get an approval. One example is that with certain insurance companies, every time I order an MRI of the lower back, they want the patient to have had a plain X-ray first. Why? There is no evidence that X-rays are a good test to diagnose back problems. In fact, if I am looking for a herniated disc, a plain X-ray will not show it but rather an MRI is needed. I know this but sometimes the only way to get the patient to get the test is to do it anyway.

– Don’t give up. If a test is denied, appeal it. I find that this is not often successful but sometimes is. Plus, the insurance company should not be given an easy pass for refusing to cover something a patient needs.

– Get the patient involved. Patients should be contacting their insurance company as well. They will be talking to member services and sometimes they find a sympathetic ear who helps them get coverage or reveals the holy grail of coverage determination to them. They are often successful when we are not.

– Remember human resources. If a patient works at a company that has an HR department, have the patient get them involved. Insurance companies do not want to lose any covered lives so if they find a company is unhappy with the services provided, this can be a very effective weapon.

– Ask for the medical director of the insurance company. Most of them were practicing medicine at some point and understand our struggles on the frontlines. If we present our medical reasoning with them, they often are able to authorize a test. Not always.

– Talk to your provider rep at the insurance company. They often know the right person to talk to that may help you get the service covered.

While these tips may help get some prior authorizations approved, they often still do not work. The insurance companies hold a lot of power over these medical decisions. The most important thing is to keep fighting the ones we don’t medically agree with. The day we all quit the battle is the day we lose the game.  Don’t let the big insurance companies win and determine medical care. We must remain diligent in our fight for optimal clinical outcomes in all and each of our patients.

By: Linda Girgis, MD

April 4, 2018

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