Within the busy provider world, locum tenens or substitute physician (s) usually assume professional practices in the absence of a regular physician for reasons such as illness, pregnancy, vacation, continuing education or even filling in while permanent providers are recruited. First, At the time this was written, not being of the same specialty may have been allowed, but since then CMS has stated for example, radiation therapy cases using Intensity Modulated Radiotherapy (IMRT) and Image Guided Radiotherapy (IGRT) the physician must have the appropriately training and expertise acquired within the freamework of an accredited residency and/or fellowship program in the specialty/subspecialty, i.e. The substitute physician does not provide services to the beneficiary over a continuous period of more than 60 days. No authorization or referral is required by any Cigna medical plan for emergency care. capitation) at regular intervals for each participant assigned to the physician, group, or PHO, whether or not services are provided. All insurance policies and group benefit plans contain exclusions and limitations. The Q6 modifier must also be added to each CPT code on the claim. Clinical Policy Bulletins View medical, dental or pharmacy clinical policy bulletins. 1. Due to the quick growth urgent care practices experience and turnover of physicians, it is important you know how to bill for non-credentialed providers when the need arises. hb```Y,;@ ( or would the locum be able to bill under the other doctor for 12 months if he did 5 days of coverage a month, which would equal 60 days of coverage? Privacy Policy | Terms & Conditions | Contact Us. Cigna members receive a description of their benefit packages that includes information on: exclusions and limitations, the definition of emergency care, claims, and reimbursement procedures. Physician Manual Policy Guidelines Version 2022-1 October 15, 2015 Page 3 of 45 The following policy guidelines apply to participation in the Medicaid Fee-for-Service Program. So we wouldnt be billing incident to we would be billing Locum Tenens for a non-employed Physician. A clinic may need to fill a role quickly due to the unexpected loss of a provider (i.e. Changes to the Payment Policies for Reciprocal Billing Arrangements and Fee-For-Time Compensation Arrangements (formerly referred to as Locum Tenens Arrangements) This article is based on Change Request (CR) 10090, which implements the 21st Century Cures Act (Section 16006). Many are reputable companies that clearly understand CMS rules, but others may mislead offices to think they can keep these temps long term, or use nurse practitioners as locum tenens. The locum tenens provision is widely used, but often misunderstood, which puts practices at risk if the guidelines are not followed. Outpatient physical therapy services furnished by physical therapists . November 3, 2022 8 Min Read Locum tenens defines the industry that was established in 1979 to help fill staffing gaps in rural health facilities and to give those providers some much-needed relief. With claims-made coverage, the incident must be reported while the policy is in force (again, this is typically for a one-year term); also, the incident must have occurred during the period of time covered by the policy. The regular physician is unavailable to provide the services. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. The Cigna Healthy BabiesSMprogram, available to expectant participants in our Network, POS, EPO, and PPO plans, provides educational support to help participants have a healthy pregnancy and baby.To encourage women to see their OB/GYN for regular checkups during pregnancy, there are no co-payments for prenatal visits. Only when two or more drugs are determined to be therapeutically equivalent does cost become a consideration. They render opinions that address the issue of whether the requested technology will specifically benefit the member in question and whether this technology offers advantages over currently proven treatment modalities.Medical Technology Assessment: The Cigna Medical Technology Assessment process evaluates emerging and evolving technologies to help ensure that our members have access to effective treatments. Tech & Innovation in Healthcare eNewsletter, Risks Abound for Non-credentialed Physicians Using Incident-to Rule, Medicare Claims Processing Manual, section 30.2.11, Capture the Complete Clinical Picture With Precision, Applying RVUs to Pharmacists Patient Care Services, MLN Updates Medicare Claim Submission Guidelines, Evaluation and Management: Time-Based Coding, Appeals Backlog Gone in 4 Years: Medicare. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted to prevent hospitals from determining whether a patient should pay for care before it is rendered. Locum physician services can be billed under the NPI of the doctor absent, with the Q6 modifier (service provided by a locum physician) added to each CPT code on the claim. Prior authorization is a request for coverage of a health care service or treatment that requires clinical review. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. The provider entity must notify BCBSMT of the Locum Tenens provider arrangement at least 30 days in advance of the vacancy. Emerging Treatment (Experimental)Managed care plan (Network, POS, EPO, and PPO) standards for coverage for new and emerging treatments have become subject to increased scrutiny. Continuity of CareContinuity of care concerns for participants in our managed care plans (Network, POS [Point-of-Service], EPO [Exclusive Provider Organization], or PPO [Preferred Provider Organization] plans) can be triggered by several different eventsfor example, a contract with a provider participating in a network is terminated (either by the provider or by the health plan) while a member is undergoing a course of treatment from the provider, or a member's employer selects a different health plan to provide coverage to its employees and a provider that an employee is actively receiving treatment from is not in the new network. We have developed national policies to credential practitioners and facilities that are adopted and managed at the local level by our medical management staff. Locum Tenens Malpractice Insurance: The Basics A locum tenens malpractice policy provides coverage to the physician for damages suffered by a patient resulting from professional healthcare service. There is a misperception that managed care offers physicians financial incentives to cut costs and corners when treating patients. Our Disease Management, Behavioral Health, and Wellness & Health Promotion Programs for our customers have also received NCQA Accreditation. Now lets look at how reciprocal billing works and examine approved ways for clinicians to provide service while in the process of contracting and credentialling. The identification of the locum is mostly used for auditing, to confirm provided servicesand not for payment purposes. It includes discharge planning, including assisting with arrangements for home health care services, when medically necessary.Cigna considers several sources of information to make consistent and accurate coverage determinations. The PCP leads the team helping the member to manage multiple health conditions and treatmentsoften this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed.Under certain circumstances when it is determined that the ongoing needs of a member with chronic or multiple illnesses would be most effectively met by a specialist, that specialist becomes the primary care provider for that member (for example, an AIDS patient may use an infectious disease specialist as their PCP). The council also reviews reports produced by the Technology Assessment Unit research staff at the request of field medical directors. Medicares requirement is that an on-staff physician can bill and receive payment (when assignment is accepted) for a substitute physicians services as though the on-staff physician performed them. Providers unhappy with the changes managed care has made in the way they are paid have raised the issue. We understand 60 days and Q6 but what about the EHR documentation? Do not bill for services provided by a temp while waiting for a physician to be credentialed with Medicare. Concurrent review includes the evaluation of a hospital admission by a clinicianwhile the customer is in the hospitalto ensure coverage for the appropriate care setting. Cigna, by contract, requires participating primary care physicians to maintain 24-hour, seven-day-a-week telephone coverage and to provide an appointment within 24 to 48 hours of a request for urgent medical conditions.When members are unsure whether or not they have a condition that requires immediate medical attention, they should consult with their primary care physicians. Join over 20,000 healthcare professionals who receive our monthly newsletter. Compliant . TITLE: Locum Tenens (LT) Policy . The patient has arranged or seeks to receive health care from the regular physician. Medically necessary inpatient care is also covered. The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Non-credentialed Provider Billing Criteria At a Glance: Not allowed for newly employed physicians. Please verify your coverage with the provider's office directly when scheduling an appointment. Your plan doesn't require any pre-authorizations. It is at the discretion of each woman's doctor to decide, based upon her health history, when or how often she needs a mammogram.There are two types of surgical treatment for breast cancer: lumpectomy, which is the removal of a lump from the breast; and mastectomy, the removal of the entire breast and sometimes the lymph nodes.A biopsy is a procedure used to detect cancer that involves the removal of a small amount of breast tissue for evaluation.We recognize that each woman enters surgery with a different health history and condition, and each woman recuperates at a different pace. Cigna medical professionals do not receive any financial or other reward or incentive from any Cigna company, or otherwise, for approving or denying individual requests for coverage.Utilization management includes prior authorization for certain elective surgeries, procedures, and tests. Lets look at the two billing options available for non-credentialed providers in this circumstancelocum tenens arrangements and reciprocal billing arrangements. Government should not be involved in deciding what is the best medical treatment for a particular health condition. What if a locum is covering a provider and then the provider retires, how do we continue to bill and collect for the locum. The terms of an individual's particular coverage plan document (Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document) may differ significantly from the standard coverage plans upon which these coverage policies are based. Each Cigna Network Plan and POS Plan member selects a primary care physicianusually a family practitioner, internist, or pediatrician, who becomes the cornerstone for that member's health care needs.The primary care physician is familiar with the patient and their health history and helps coordinate care for the member, including the provision of primary and preventive care and referral to specialists when needed (except in Cigna HealthCare Network Open Access and POS Access planreferrals are not required in these plans). Locum tenens providers provide hospitals with the ability to fill absences while still providing patient care. This Medicare rule applies to on-staff physicians and cannot be used for mid-levels. We have a provider was terminated and we are replacing him with a Locum Provider for 60 days only. Medical science is not static, new treatments are constantly being discovered, and changes are being made to existing treatments on a regular basis. Or under the provider they are covering for? If these coverage policies are inconsistent with the terms of the individual's specific coverage plan, then the terms of the individual's specific coverage plan always control. We are contracted with a clinic to provide coverage in our mental health unit. Ethics and Compliance Policy Committee. Drugs included in our formulary are carefully selected by physicians and pharmacists for their efficacy, and the formulary is reviewed and updated regularly. Cigna may not control the content or links of non-Cigna websites. PO Box 55290. These professionals use established guidelines to help them make decisions about whether a procedure is medically necessary based upon the specific facts of each coverage request. The terms of your plan will tell you what benefits you are eligible for. Mental health advocates are now seeking state legislative mandates that would require mental health coverage be provided in all health plans at the same level of benefits as physical illness. capitation and fee-for-service).Consequently, we have never imposed restrictions on health care-related communication between physician and patient. Clinical Guidelines Dental Clinical Policies and Coverage Guidelines Requirements for Out-of-Network Laboratory Referral Requests Protocols UnitedHealthcare Credentialing Plan 2023-2025 Credentialing Plan State and Federal Regulatory Addendum: Additional State and Federal Credentialing Requirements Policy and Protocol news 757 0 obj <>/Filter/FlateDecode/ID[<00C559F83C6DDE479F456DAE1856E7AB>]/Index[739 35]/Info 738 0 R/Length 89/Prev 171903/Root 740 0 R/Size 774/Type/XRef/W[1 2 1]>>stream In those cases, most health plans just need an updated roster of providers offering services under the clinic agreement. The study is flawed in several ways, the most important of which is that it does not establish any baseline for results (for example, it does not look at drug costs and drug/medical utilization patterns at the HMOs studied prior to the effective date of the formularies).The Cigna formularya list of drugs covered by a member's benefit planwas developed to assure quality and cost effective drug therapy. A locum tenens physician cannot be used to cover expansion or growth in a practice. I need your help in issue and the issue is {We have two different services for two different Locum Tenens providers but their Supervising provider is same and we are billing the claims for the locums under Supervising physician NPI with Modifier Q6} Now we have one E&M service for a locum and the other service is EKG for a different locum and we have to bill 2 claims under the same supervising physician now i need to know that do we need to add modifier 25 with E&M claim? UPDATE: Effective June 23, 2017, CMS changed its locum tenens policy, and expanded it to include physical therapists. All insurance policies and group benefit plans contain exclusions and limitations. If the physician has left the practice, every claim still must have a rendering provider, so the practice would still use his or her name and NPI with modifier Q6 Services furnished by a locum tenens physician appended to the procedure code to indicate the service was furnished by an interim physician. Leverage our contracting and credentialing experience. The Susan Horn Study), concluded that use of formularies increased use of health care services, which resulted in lower quality and increased costs. Additional coverage policies may be developed as needed or may be withdrawn from use. We believe that our members should be fully informed. Also can a locum be used when a provider retires, until a permanent replacement can be found? Requests for coverage of an alternative therapy are reviewed on a case-by-case basis by the local Cigna HealthCare physician-medical director to determine if the treatment has been proven scientifically to be effective (for example, supported by peer review literature) and whether its covered under the members benefit plan. Consumer education and preventive care are the most significant tools a managed care company has to keep health care affordable and provide access to quality care.Quality health care is possible only when there is an open, unencumbered dialogue between physicians and their patients. that insure or administer group HMO, dental HMO, and other products or services in your state). Is there a timeframe the locum has to start after the provider has taken leave? 4. Not sure if this is the same as Locum Tenens. Prior Acts or Tail Coverage. Shorter or longer lengths of stay may be approved at the request of the attending physician.Medically necessary home care services are available following discharge from the hospital. Necessary mammograms, when ordered by a woman's physician or OB/GYN, are covered. The general public is under the false impression that managed care companies do not provide coverage for new treatments, drugs, or devicesoften called experimental treatmentbecause they are expensive and unproven. Fast Facts About Locum Tenens Coverage August 30, 2021 Due to the rising shortage of physicians, many healthcare organizations are using locum tenens physicians to fill the gaps. Cost is an appropriate and necessary consideration, since drug prices have risen three times faster than the rate of inflation over the last decade.We offer a variety of formulary structures, depending on the level of prescription drug coverage your employer chooses to offer. Our Utilization and Case Management services have been awarded accreditation from URAC, an independent, not-for-profit organization whose mission is to ensure consistent quality of care for clients and customers. Locum Tenens Definition: A locum tenens is considered a substitute physician, who is only intended to fill in for an absent physician and does not plan to join the urgent care practice. Utilization Management-DentalUtilization management (UM) is a program we use to make sure our customers get coverage for appropriate care. This relationship facilitates better treatment in the emergency room because the primary care physician can alert the emergency room that the patient is coming and provide important details on the patient's condition and health history.As a Cigna plan participant, you have access to the Cigna 24-Hour Health Information LineSM. What advice do you have to share with others considering these type of billing arrangements? Open access encourages women to take advantage of preventive care including pre-pregnancy planning, to access maternity services earlier, and to seek covered OB/GYN services. Organized medicine has just begun to look at the benefits of certain alternative treatments.The Cigna Medical Technology Assessment Council regularly reviews new treatments and technologies to help ensure that our members have access to effective treatments. Within this article there is a statementDo not bill for services provided by locum tenens while waiting for a physician to be credentialed with Medicare. She is not credentialed as of yet and with our Physician out of the office we are curious to know if we can use her as Locum Tenens, until credentialing process is complete and hire her on. We are in the same boat however with a NP. Requests for coverage for off-label drug use are reviewed on a case-by-case basis. Most specialists do not meet the training requirements to be primary care providers.For HMO and POS plan members with complex health conditions, the role of the primary care physician is essential. Copyright 2023, AAPC Private practice / Locum Tenens physician . There is a misperception that health plans do not give their members basic information about the plan such as: what is contained in the benefit plan they have selected, how to access services, which providers are in the network, what is the appeal and grievance procedure, etc. Financial Incentives/Provider ReimbursementThe manner in which health plans reimburse providers is another issue that is coming under increased public scrutiny. Reason #2: Temporary or Substitute Hire Locum Tenens is not as simple as putting a modifier on a claim when another physician sees patients in your office. Medically necessary home health care services are available following breast surgery procedures.Following a mastectomy, Cigna medical plans provide coverage for breast reconstruction when appropriate. These professionals follow guidelines to help them decide if a procedure is medically necessary. Can you use a locum for other providers such as a massage therapist or certified rolfer? Commitment to QualityWe promote health by providing: We measure the effectiveness of our program activities by seeking external validation of our programs. Easier access to OB/GYNs encourages women to take advantage of preventive care, to access maternity services earlier, and to seek help for covered OB/GYN services. Locum tenens physicians working with claims-made policies should make sure that the staffing . If you need specialty care, your primary care dentist will give you a referral. After the 60-day limit expires, an urgent care clinic may no longer bill for that locum physician. 2017-06-13. that insure or administer group HMO, dental HMO, and other products or services in your state). They have seized this issue and are seeking legislation that would guarantee payment for all treatment provided in emergency rooms, regardless of the medical necessity of the services. As a practice grows, new providers are needed to manage heavier patient flow. Physicians are eligible for a bonus at the end of the year based on quality of care, quality of service, and appropriate use of medical services. Locums typically fall into one of two categories for billing purposes: "true locums" and supplemental . We will be billing on a HCFA 1500 form. Locum tenens physicians may not bill Medicare; they should be paid on a per diem or similar fee-for-time basis. B. Health plan medical directors use utilization management guidelines to assist in making such coverage determinations, but they are used as just thatguidelinesand are not a substitute for a clinician's judgment. In the early 1970s, a federal grant was awarded to the University of Utah for the purpose of providing physician staffing services to rural health clinics in medically under-served areas of the western United States. HEDISis a registered trademark of the National Committee for Quality Assurance (NCQA). Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see