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Addressing Physician Staffing Challenges Under Medicare

Posted on 09/20/15

Dealing with physician staffing challenges can be daunting, especially when working within Medicare’s regulations. Here are a few guidelines for consideration when working with locum tenens physicians and new physicians who are awaiting credentialing.

Locum Coverage

When employing the services of locum tenens physicians during a time of critical staffing need, it’s important to keep the following in mind:

  • The locum cannot be an employee of the regular physician
  • The locum will be paid on a per diem or similar fee-for-time basis by the regular physician
  • The locum does not have to be enrolled in the Medicare program to see patients, but must have an NPI and be licensed in the state of practice
  • A physician who is awaiting credentialing cannot be billed as a locum; this is only appropriate for absent physicians
  • The locum provision only applies to physicians. The absence of a non-physician practitioner (NPP) cannot be covered by a locum physician
  • Locum coverage cannot be used in the case of the death of a physician
  • The period of coverage for the regular physician cannot exceed 60 days
  • In the case of recruiting a physician replacement, the 60-day coverage period still applies. If the physician vacancy is not filled within the initial 60 days, a NEW locum must be used for the next 60 days of coverage
  • The 60-day coverage period runs consecutively, with no breaks, even if the locum does not see patients on some of those days

New Physician Credentialing

While a new physician in your practice is awaiting credentialing from Medicare, these guidelines apply:

  • The physician can treat Medicare patients while awaiting enrollment. Medicare will accept an application 60 days prior to the provider’s requested start date. Claims are held until the enrollment process is complete. The effective date with Medicare should be 30 days prior to the date the enrollment application was received by Medicare.
  • The new physician can treat all other insured patients as an out-of-network provider, as long as the patient has out-of-network coverage with their insurance plan
  • When seeing the patient as an out-of-network provider, the patient should be notified in advance that their out-of-pocket cost will be higher than if they were treated by an in-network provider
  • The physician awaiting credentialing cannot bill under another physician within the group. The incident-to provision does not apply to physicians

With a predicted shortage of up to 90,000 physicians by 2025 according to a recent Association of American Medical Colleges report, the likelihood that your practice will deal with a staffing challenge is an unfortunate reality as the need for physicians continues to escalate. It’s important to understand the guidelines and be prepared to minimize the impact on your patients and the practice.

If you have additional questions, please contact your KB Healthcare Consulting Senior Medical Consultant, Johna Kennedy-Preston, CPC, at (941) 953-7451 ext. 1423 or .

About the Author

Johna Kennedy-Preston

Kerkering, Barberio & Co.
1990 Main St., Suite 801
Sarasota, FL 34236
(941) 365-4617

Ms Kennedy-Preston provides clients with expertise in revenue cycle management, coding education, managed care contracting, mergers and start-up ventures, Medicare recoupment and reporting issues, credentialing with insurance carriers and assistance with state and federal licensing. Guidance is also supplied for operational improvement, policy development, procedure design and implementation, including electronic health record set up and workflows, compliance with third-party due diligence and regulatory requirements, as well as training of healthcare professionals in critical topics, both fundamental and emerging.

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