By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
April 3, 2019
Things happen in life to take a physician (optometrist) away from a practice for a period of time. A few examples of this would be illness, pregnancy, vacation, bereavement, or even continuing education.
During this time, it is reasonable for the practice to retain a substitute optometrist to take over seeing patients during the regular optometrist’s absence. As with everything, there are rules that must be followed. Here is what you need to know.
The CMS Manual for Medicare Claims Processingi and the Medicare Learning Networkii article covering this topic both state:
“The term “locum tenens,” which has historically been used in the manual to mean fee-for-time compensation arrangements, is being discontinued because the title of section 16006 of the 21st Century Cures Act uses “locum tenens arrangements” to refer to both fee-for-time compensation arrangements and reciprocal billing arrangements.
What is a fee-for-time compensation arrangement? This occurs when an optometrist, not employed by the practice, steps in to cover for the regular optometrist who is away from the practice for an extended time. The practice pays the substitute optometrist on a per diem compensation basis. The status of the substitute optometrist is an independent contractor.
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What is a reciprocal billing arrangement? A reciprocal billing arrangement is an agreement between optometrists (not part of the same practice) to cover each other’s practice when the regular optometrist is away. The practice can set up reciprocal billing arrangements with more than one optometrist. This can be an informal arrangement (i.e.: it is not required to be in writing). The practice pays the substitute optometrist on a per diem compensation basis. The status of the substitute optometrist is an independent contractor.
Services submitted under a fee-for-time compensation arrangement or a reciprocal billing arrangement must meet the following criteria – the regular physician is unavailable to provide the services and Medicare beneficiaries are scheduled to receive the services from the regular physician.
How long can the substitute optometrist provide services?
The substitute optometrist is limited to providing services over a continuous period of up to 60 days. The continuous period occurs whether the substitute optometrist is actually seeing patients or not. It starts the first day the substitute optometrist provides services and continues until the regular optometrist returns.
If the continuous time the regular optometrist is away is longer than 60 days, then another substitute optometrist must be used. The exception to this is if the regular optometrist …
“… is called or ordered to active duty as a member of a reserve component of the Armed Forces for a continuous period of longer than 60 days, payment may be made to that regular physician or physical therapist for services furnished by a substitute under reciprocal billing arrangements or fee-for-time compensation arrangements throughout that entire period.”
An example here will help with understanding how time is used in this calculation.
“EXAMPLE: The regular physician … goes on vacation on June 30, and returns to work on September 4. A substitute physician … provides services to Medicare Part B patients of the regular physician … on July 2, and at various times thereafter, including August 30 and September 2. The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days. Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician … is not entitled to bill and receive direct payment for the services furnished August 31 through September 2. The substitute physician … must either bill for the services furnished August 31 through September 2 in his/her own name and billing number or reassign payment to the person or group that bills for the services of the substitute physician or physical therapist. The regular physician or physical therapist may, however, bill and receive payment for the services that the substitute physician … provides on behalf of the regular physician … in the period July 2 through August 30.”iii
How does billing work?
How do you bill for this? The regular optometrist submits the claim under their own NPI, using the appropriate procedure codes, and the appropriate HCPCS modifier. Use modifier Q5 for reciprocal billing arrangements and modifier Q6 for a fee-for-time arrangements.iv
Under this system, the regular optometrist, not the substitute optometrist, receives any Medicare payment for the service. Do not pay the substitute optometrist a salary or have a revenue-based payment model (i.e.: productivity incentive). Anything other than a per diem fee is in violation of what constitutes a temporary optometrist.
Is Additional Record Keeping Required?
Another rule to follow is about record keeping. The practice for whom the provider is filling in must maintain a record of each service provided by the substitute optometrist, the dates of the service, along with the substitute optometrist’s NPI number. These records are essential during an audit.
Can I use this approach during the credentialing process for a new hire optometrist?
In a word, no. If you try this, you may get paid, but during an audit you could face serious repercussions. It’s best to contact your carriers directly and ask them what to do.
Most state Medicaid plans follow CMS guidelines, but the best approach is to contact your local carriers for specific information. Rules vary among commercial plans, so again, check with your local carriers for specific guidelines.