Medicare Compliance & Reimbursement

Question: Our practice just hired a new provider. They have their medical license, but they’re waiting for their National Provider Identifier (NPI) to be able to bill Medicare for services rendered. We heard they can just bill under another physician’s number or bill as a locum. Is that OK?

South Dakota Subscriber

Answer: It may be tempting to bill services under another provider while you’re waiting for the new physician’s credentialing to come in — but don’t do it. You should not use another credentialed practicioner’s NPI on the new provider’s claims to get paid for services the new physician performs before being credentialed. Doing this is considered fraud since your practice would be saying that Doctor A performed a service that Doctor B actually provided.

Solution: Either avoid having the new physician see patients until the Medicare or private payer credentials come through, or have the physician see only patients who are self-pay or who have insurance that allows you to bill before credentialing.

Remember: You cannot just report the new provider’s service under an existing physician’s ID number and append the locum tenens modifier to it.

Here’s why: Locum tenens means “to hold the place of” in Latin. When you bill for locum tenens, you are billing for a covering physician as if they were the regular physician — and that is not the case with a new physician at your practice.

Additionally, Medicare has certain parameters that need to be met in order to bill locum tenens, which are laid out in Chapter 1 of the Medicare Claims Processing Manual. Many private payers adopt similar policies.

Practices that simply report the new physician’s service as if it was performed by a locum tenens doctor, are going against the original intent of the locum tenens rules.