Locum Tenens/Reciprocal Billing Arrangements

Locum Tenens/Reciprocal Billing Arrangements A. Locum Tenens: For purposes of this rule a “locum tenens” arrangement is defined when the regular physician retains a substitute physician to take over the practice during an absence. A regular physician is the physician that is normally scheduled to see a patient. The regular physician usually pays the substitute physician a fixed amount per diem, with the substitute physician being an independent contractor rather than an employee. B. Reimbursement shall be made to the patient’s regular physician for covered services of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices when all the following criteria are met: 1. The regular physician is unavailable to provide the services, 2. The regular physician pays the locum tenens for the services on a per diem or similar fee- for-time basis, 3. The Medicaid beneficiary has arranged or sought to receive services from the regular physician, 4. The substitute physician does not provide the services to the Medicaid beneficiary over a continuous period of longer than sixty (60) days, 5. The locum tenens physician is an enrolled Mississippi Medicaid provider with a valid Mississippi Medicaid provider number, 6. The regular physician identifies the services as substitute physician services, 7. The claim is billed with the National Provider Identifier (NPI) of the regular physician, 8. The regular physician keeps on file a record of each service provided by the substitute physician, and 9. The regular physician ensures that the locum tenens physician is properly licensed to practice medicine in the state of Mississippi; or, if the regular physician practices in another state, the state in which the regular physician is licensed to practice. C. Reciprocal Billing Arrangement: Medicaid defines reciprocal billing arrangement when a regular physician or group has a substitute physician provide covered services to a Medicaid beneficiary on an occasional reciprocal basis. A physician can have reciprocal arrangements with more than one physician. The arrangements need not be in writing. 1. Medicaid covers reciprocal billing arrangements when the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if all the following criteria are met: a) The regular physician is unavailable to provide the services, b) A reciprocal billing arrangement is typically an agreement among physicians that one will cover the other’s practice when the regular physician is absent. Physicians can have reciprocal arrangements with more than one physician, c) The Medicaid beneficiary has arranged or sought services from the regular physician, d) The substitute physician does not provide the services to a Medicaid beneficiary over a continuous period of longer than sixty (60) days, e) The substitute physician is an enrolled Mississippi Medicaid provider with a valid Mississippi Medicaid provider number, f) The regular physician identifies the services as substitute physician on the appropriate claim form, g) The regular physician keeps on file a record of each service provided by the substitute physician, associated with the substitute physician’s National Provider Identifier (NPI), and h) The regular physician ensures that the substitute physician is properly licensed to practice medicine in the state of Mississippi; or, if the regular physician practices in another state, the state in which the regular physician is licensed to practice. 2. Medicaid does not cover reciprocal services for substitution arrangements among physicians in the same medical group except when a group member provides services on behalf of another group member who is the designated attending physician for a hospice patient. D. Covered Visit Service - Medicaid covers the submission of claims for a medical group under reciprocal billing arrangements for the covered visit services of a substitute physician who is not a member of the group. Medicaid defines a continuous period of covered visit services that begins with the first day on which the substitute physician provides covered visit services to patients of the regular physician, and it ends with the last day on which the substitute physician provides these services to these patients before the regular physician returns to work. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or are furnished by some other substitute physician on behalf of the regular physician. A new period of covered visit services can begin after the regular physician has returned to work.