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Urgent care clinics, take note. The Centers for Medicare and Medicaid Services (CMS) is asking for your help in determining the future of substitute physician billing arrangement criteria. This involves both reciprocal billing and locum tenens arrangements—both are widely used in urgent care.

Urgent cares regularly bill with both these arrangements due to the fluid nature of physician employment and fast growth of urgent care practices. Physicians often join a growing urgent care clinic before credentialing is completed. Also, substitute physicians are needed for regular physicians who are absent due to vacation, illness, or termination.

The CMS “has concerns about the operational and program integrity issues that may result from use of substitute physicians to replace a physician who has permanently left a practice or to fill staffing needs.” The CMS policy currently does not allow substitute physicians to regularly fill in for a physician who has left the practice, and has concerns this is occurring.

Regarding billing for Medicare, currently the substitute physician’s national provider identifier (NPI) is not included on the claim. Services provided by substitute physicians are currently noted by a modifier line on the claim. In addition, the CMS can’t prove credentials of the substitute physician as it does not currently require substitute physicians to be enrolled in Medicare.

The CMS wants to better understand current industry practices for substitute physicians and is soliciting comments. Because changes to CMS regulations could drastically affect urgent care billing practices, DocuTAP encourages you to share your opinion with the CMS.

Comments are requested by September 2, 2014 by 5 p.m. (EST) and can be submitted the following ways (please refer to File Code CMS-1612-P when submitting):

Submit in only one (1) of these four (4) ways:

1. Electronically at Follow the instructions for “submitting a comment.”

2. Regular Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1612-P, P.O. Box 8013, Baltimore, MD 21244-8013

3. By Express/Overnight: Centers for Medicare & Medicaid, Department of Health and Human Services, Attention: CMS-1612-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850

4. By Hand/Courier: Washington D.C., Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW.

The CMS would like your comments on the following items regarding the industry practice and use of substitute physicians:

1. How substitute physicians are currently utilized and how physicians and other entities are billing for such services.  CMS would like specific examples including the circumstances that give rise to the need for substitute physicians, the types of services rendered, the billing for the services, the length of time that services are needed or used and other information regarding the arrangement.

2. When a physician is “unavailable” (as per the Act, section 1842(b)(6)(D)) and what that means in terms of physicians, medical groups and entities that utilize the services of a substitute physician when the regular physician is “unavailable”.

3. Whether CMS should limit substitute physician billing arrangement to hose “between the two physicians” rather than between a medical group, employer or other entity and the substitute physician.

4. Whether CMS should permit the sequential use of multiple substitute physician provided that each substitute physician furnishes services for the absent physician no more than 60 continuous days.

5. Whether CMS should have identical or different criteria for locum providers versus reciprocal providers.

6. Whether substitute physician should be required to enroll in the Medicare program.

7. Whether claims being submitted should include the identity of the substitute physician and, if so, whether the CMS-1500 and/or electronic equivalent should be revised to accommodate this.

8. Whether CMS should place limitations on the use of substitute physicians and billing for those services (for example, including length of time for use when a physician had left the practice and a requirement that the departing physician be a party to the substitute physician billing arrangement; or permitting the use of substitute physician only where a demonstrated staffing need can be shown). They also want comments on whether these limitation should be different depending on the reason requiring the use of the substitute physician.

9. Whether CMS should limit or prohibit the use of substitute physician billing arrangement in certain programs for certain purposes (example of the Medicare Shared Savings Program or determining whether a physician is a member of a group practice for purposes of the physician self-referral law).

10. The impact of substitute physician billing arrangements on CMS programs that rely on PECOS enforcement of the physician self-referral law and program integrity oversight.

11. Additional program integrity safeguards that should be included in the CMS policy to protect again program and patient abuse. These could include but are not limited to, qualification of substitute physicians related to exclusion status, licensure, quality of care and certifications.

12. Any other issue that should be considered.

Reference: (pages 40382-40383)

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.

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