Practice Management Alert

Mastering the details of reciprocal and locum tenens billing is enough to make any medical office biller want to take a long leave of absence. But if you don't understand and follow the rules, you are leaving your practice vulnerable to denied claims and compliance violations. Reciprocal billing means that one doctor has promised to see another doctor's patients while she is away. The absent doctor later returns the favor when needed, says Lisa Johnson, CPC, CCS-P, a senior consultant with Gates, Moore and Company, based in Atlanta.

You shouldn't file reciprocal billing claims for call coverage within medical groups, Johnson stresses. Reciprocal billing does not apply to substitute arrangements within a medical group for claims submitted under a group name, she says. When applicable, substituting under reciprocal billing arrangements benefits both the regular and substitute physician. A regular physician who is unavailable to see patients secures for them continued quality service without losing payment for her time away. The substitute physician fills in for his fellow physician without the hassle of creating new files for patients who are unlikely to be seen again during the changeover, say Susan Callaway CPC, CCS-P, a coding and reimbursement specialist in North Augusta, S.C. Under a similar arrangement called locum tenens, the regular physician receives payment for time off but then parcels out a fee-for-time payment to the substitute who provides a service on a more regular basis (see related article 2). Guard Against Compliance Risks To legitimize payment, your claims must be absolutely clear and up-front about reciprocal billing arrangements. Here's an example of how reciprocal billing can present compliance risks. Let's say Dr. Smith has worked 20 years for a busy internal medicine practice and finally takes time off for an eight-week vacation. She asks her trusted colleague Dr. Jones to see her regular patients while she's gone. However, the practice doesn't note this arrangement in its records or claims because the two doctors assume they have worked out a private agreement and that Dr. Jones is simply doing his friend a favor. But what looks like a favor to the doctors may look like a bunch of false claims to a payer. Private agreements for substitute physicians need a mention in the regular physician's claim. Fudging this detail invites denials. Your local Medicare carrier might find out about the slip-up during a random inquiry and deny your physicians for two months of service, Johnson warns. Reciprocal Billing Criteria When you submit a reciprocal billing claim to Medicare, you should verify the following, Johnson advises: The patient arranged or sought to receive covered services from a regular physician. The regular physician was unavailable. The substitute physician who replaced the regular physician provided [...]