By: Ray Jorgensen, Co-Founder, PMG Credentialing

For the past 25 years working in/around the health center marketplace, I have been amazed, perplexed, and most often baffled at the ubiquitous use of “locums.” Regularly I would hear “we are billing locums.” Or “We use locums…” at this location or on this day or during planned or unplanned leave. Too many talk about “locums” as if it is commonly understood or interpreted by payers, health centers, and providers.

Locums is short for the Latin term “Locum Tenens” which Merriam Webster defines as “one filling an office for a time or temporarily taking the place of another—used especially of a doctor or clergyman.”  In healthcare, the Medicare Claims Processing Manual (MCPM), Chapter 1, Section 30.2.11, discusses the historic and common practice of a provider billing under another provider’s name. As section B clearly states: “The regular physician generally pays the substitute physician on a per diem or other fee-for-time compensation basis with the substitute physician having the status of an independent contractor, rather than of an employee, of the regular physician.” Billing is submitted under the name and NPI of the provider for whom the temporary person is filling.

While the above clearly seems to convey the ability for “coverage” by another provider, health centers should be wary for several specific reasons:

1. This language/provisions applies nationally but ONLY to Medicare and (as paragraph B of the aforementioned Section 30.3.11 says) only for Medicare Part B. Medicare Part A is the Medicare side of the house adjudicating 837-I claims seeking PPS payment… the lion’s share of health center Medicare money. Part B only pays health centers for the technical component of diagnostics or inpatient care.

2. Medicaid policy varies state to state. For most health centers, Medicaid is the primary payer. As such, health center’s should assure their legal counsel affirms: a. The existence of written “locums” policy for Medicaid, and b. How the health center will assure compliance. 

3. There is no national policy for locums. Every commercial payer and state Medicaid may create and enforce unique standards. Know the rules, policies, statutes, etc. for health center payers or run the risk of fraudulent billing.

4. Billing a new provider under an existing provider (e.g., Medical Director) is not justified as “locums” billing. New providers and new locations need to be enrolled. Unless a payer tells a health center in writing that is permissible to bill under an existing provider’s number, just don’t do it.

5. Just because a “locums” company says a health center can bill does not make it so. Look, sales people get paid to sell not know, federal, state, or commercial payer billing statutes or regulations. It is always the health center’s responsibility to know the rules and do things the right way.

In the end, it probably makes the most sense to create a roster of local providers who occasionally fill in when regular providers have a planned or unplanned absence. Getting these  temporary providers enrolled with all the payers (or at least those covering 80-90% of a health center’s payments) will go a long way in mitigating issues from billing under the wrong provider. 

And, working with a qualified credentialing and enrollment firm that understands health center requirements will expedite enrollment of both periodic and regularly scheduled staff. Contact PMG  Credentialing today to learn how.