Adding a physician or other health-care professional (eg, physician assistant or nurse practitioner) to a retinal practice is challenging. Practices frequently ask us how they can start billing for a new physician right away. Here is our advice.

Q. Are we allowed to have a senior doctor sign off on the new doctor’s charts?

A. No. You may not substitute the name of a credentialed doctor (Dr. A) for the new doctor (Dr. B) on claims while waiting to finalize enrollment paperwork. The error is magnified if you ask the credentialed doctor to co-sign all the charts for the new doctor without seeing the patient.

Q. What’s the problem?

A. If Dr. A did not personally perform the service, he cannot claim reimbursement for services performed by Dr. B. This is a false claim under the Federal False Claims Act. The Centers for Medicare and Medicaid Services has a resource on the topic.¹ A false claim will be met with civil and, sometimes, criminal penalties.

Q. Are these cases ever prosecuted?

A. Yes. In 2017, the US Department of Justice issued a press release announcing the conviction for health-care fraud of a clinic manager and a Houston physician “…where she signed patient medical records for patients she had not seen or examined.”²

Another case, involving an ophthalmologist, makes the same point.³ According to a 2012 press release from the Federal Bureau of Investigation, the ophthalmologist was sentenced to 87 months in prison for a health-care fraud scheme that involved submitting fraudulent claims that caused more than $1.8 million in payments from Medicare and 31 other health insurers. “The patients had been seen by other physicians in the office, but [physician] falsified the charts by making notations indicating that he had personally seen and evaluated the patients.”

Most states have similar laws. Simply put, Dr. A must participate in a significant way in the evaluation and management of a patient for whom he intends to file a claim for reimbursement. You may not substitute one physician for another on a claim to speed up payments during the credentialing process.

Q. But what can we do?

A. The practice has 2 viable options to get paid for Dr. B’s services without getting into trouble:

1. Holding claims, and
2. Billing locum tenens.

To be sure, both approaches have their limitations. When neither is workable, schedule Dr. B to see patients out-of-network, without insurance coverage, or for noncovered services.

During the time you are enrolling Dr. B in the Medicare program, she is permitted to see patients; however, the claims must be suspended until the enrollment process is completed. You may submit your enrollment application to Medicare 60 days before Dr. B begins working for your practice. So, even though there is a delay in receiving payment, you don’t lose money. Other payers have their own rules, and many do not permit retroactive claims, so be sure to check your payer contracts.

Locum tenens, which is defined as, “One filling an office for a time or temporarily taking the place of another — used especially of a doctor or clergyman,” is another option. In practical terms, it means to temporarily substitute one physician for another.⁴

Locum tenens billing is most commonly used when a physician is ill (but not deceased),⁵ temporarily disabled, on sabbatical, on a long vacation, or otherwise unavailable to see patients. Locum tenens does not apply if the regular physician is available to provide services, as is the case when you are adding a new physician rather than substituting for a physician who is out. It is frequently advocated as a way to get payment for Dr. B, but there are strict limitations — including a 60-day limitation. Claims are submitted using the absent physician’s NPI with modifier Q6. The catch is that you may not use this approach once you have started the enrollment process for Dr. B.⁶

Locum tenens may be a useful short-term solution (remember the 60-day limitation) in an emergency. However, once you know Dr. B is joining your group, you are much better off beginning the enrollment process and holding her claims.

Q. Are there other alternatives?

A. Another approach is possible if Dr. B sees patients along with Dr. A. The attraction of this idea is the socialization of the new physician under the auspices of the senior one, particularly if Dr. A is planning to retire soon. The patient sees both doctors, but generates just one bill — for Dr. A. There is no claim for Dr. B. This begs the question of income for Dr. B, yet it may be your best option if holding claims and locum tenens are impossible. RP

REFERENCES

1. Medicare Learning Network. Avoiding Medicare fraud and abuse: a roadmap for physicians. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf . Accessed March 3, 2020.
2. United States Department of Justice. Clinic manager heads to prison for health care fraud. Press release. March 6, 2017. Available at: https://www.justice.gov/usao-sdtx/pr/clinic-manager-heads-prison-health-care-fraud . Accessed March 3, 2020.
3. United States Federal Bureau of Investigation. Former chair of Temple’s ophthalmology department sentenced for health care fraud. Press release. March 29, 2012. Available at: https://archives.fbi.gov/archives/philadelphia/press-releases/2012/former-chair-of-temples-ophthalmology-department-sentenced-for-health-care-fraud . Accessed March 3, 2020.
4. CMS Medicare Claims Processing, Transmittal 3774. May 12, 2017. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3774CP.pdf . Accessed March 3, 2020.
5. Palmetto GBA. Frequently asked questions – locum tenens. Available at: https://www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Providers~JM%20Part%20B~Browse%20by%20Topic~Frequently%20Asked%20Questions?open&Cat=Locum%20Tenens . Accessed March 3, 2020.
6. Medicare Claims Processing Manual §30.2.11.C. Requirements applicable to physician medical group or physical therapy group claims under fee-for-time compensation arrangements. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf . Accessed March 3, 2020.