Take Heed When Taking Off

All physicians must at some time be absent from their practices. The absence may be planned, such as for a vacation or to attend continuing medical education, or it may be unplanned, as in the event of physician illness or injury. Advance planning will help make the physician's departure and return go smoothly and without disruption to patients, the practice, or reimbursement processes. Here are some steps to take:

Notify patients

Every physician is aware that treating a patient without having full information about the patient's condition can increase the risk of medical malpractice liability. The risk increases when a patient has established only a minimal personal relationship with the physician, and they can be significant when a physician leaves the practice and a substitute physician takes his place.

In fact, a Louisiana court found that the failure to notify patients about the impending absence of a physician and the failure to make the replacement physician aware of an at-risk patient's medical history might contribute to medical malpractice liability.

To help minimize these risks, the practice or individual physician should consider giving patients advance notice if a physician absence is planned, and to take reasonable steps to inform the replacement physician of patient issues that could arise. The regular physician may wish to notify patients that he or she will be unavailable and for how long, and spell out what arrangements the practice has made to meet patients' medical needs during the physician's absence.

Although a mass mailing to all active patients would not be necessary, the notification should be documented in some way -- for example, by including a notice with billing statements in the weeks leading up to and during the absence. Verbal reminders to patients who come in before the physician departs and who schedule appointments with the absent physician are also recommended.

Ensure that any substitute physician has full, unimpeded access to patient medical records so that any applicable patient history is available to the treating physician.

Finally, the regular physician should notify the replacement physician of any patients who have special needs or who may be at-risk during the physician's absence. The regular physician might, for example, leave a list of pregnant patients whose delivery dates are imminent, or of brittle or unstable diabetic patients known to the physician.

Consider specialty

It is not uncommon for family practice physicians to substitute for specialists during periods of temporary absence. Unfortunately, coverage of a practice by a physician who is not certified in that specialty can raise the risk of medical errors and liability for medical malpractice. Make sure replacement physicians are appropriately certified or otherwise qualified in the specialty routinely practiced by the absent physician.

License, please

Physicians must be licensed by the state in which they practice -- every state has a law to this effect. The exception to this rule occurs when a physician practices in a federal facility, which may permit the physician to practice there even though he is licensed in another state. Accordingly, if a replacement physician will practice medicine other than in a federal facility, such as a physician's private office or at a state-licensed hospital, the practice must ensure that the replacement physician holds appropriate state licensure.

Check for exclusions

If a physician or practice participates in Medicare or Medicaid, it is extremely important to make sure that the substitute physician has never been suspended, excluded, or barred from participating in any government healthcare program, such as Medicare, Medicaid, and TriCare.

Federal law prohibits the payment by any federal healthcare program for any items or services furnished by an excluded individual or entity, or directed or prescribed by an excluded physician. In fact, the Office of Inspector General (OIG) issued a Special Advisory Bulletin in September 1999, which states that there is an affirmative duty to check the program exclusion status of any potential employee or contractor. If a healthcare provider employs or contracts with an excluded person, the provider may be subject to civil money penalties, other assessments, and program exclusion for rendering services that are reimbursed under a federal healthcare program for the excluded person's services.

For liability to be imposed, the provider must "know or should know" that the person rendering services is an excluded person.
Before entering into an arrangement with replacement or substitute physicians, check the OIG List of Excluded Individuals/Entities, which can be viewed on the OIG's Web site (www.oig.hhs.gov/fraud/exclusions/listofexcluded.html).

Verify malpractice coverage

If the regular physician or practice hires a temporary replacement from a locum tenens company, that company will typically provide malpractice insurance for the substitute physician. Locum tenens placement organizations in good standing with the National Association of Locum Tenens Organizations should ensure that malpractice insurance is in place for every day worked by the temporary physicians they place.

In any case, the regular physician should learn the terms of the insurance policy, and whether the policy has tail coverage to protect the practice after the temporary physician moves on to other assignments. If the locum tenens physician is not working through a placement company, the regular physician, hospital, or medical practice must typically provide malpractice insurance and written proof of coverage to the substitute physician.

Understand billing rules

Like malpractice coverage, the provisions for billing and reimbursement for a replacement physician's services may differ depending upon whether the physician coverage is obtained privately or through a locum tenens agency. A locum tenens company may provide a list of pay rates it will charge the regular physician for the locum tenens physician's services. Some states require that work done by substitute or locum tenens physicians be submitted to payers in the name of the regular physician or that physician's group.

For Medicare billing, two physicians may set up substitute billing arrangements for 60 continuous days or less. The arrangement must be informal and reciprocal, per diem, or another fee-for-time arrangement. In the case of care provided by a locum tenens physician, the regular physician should submit the claim with a -Q6 modifier, which identifies the services as those performed by a locum tenens physician. The regular physician must keep a record of services provided by the locum tenens physician, as well as the locum tenens' UPIN (Universal Provider Identification Number).

If the arrangement is a recurring relationship, physicians may establish an occasional, reciprocal billing arrangement with a substitute physician. In this type of arrangement, the regular physician can be paid by Medicare for services provided, as long as the -Q5 modifier is included on the Medicare claim form (which indicates services were provided by a substitute physician).

Obtain hospital privileges

Hospitals have a duty to screen the physicians who will potentially cover for absent staff physicians. If coverage responsibilities for the replacement physician will include hospital coverage, either for inpatient and outpatient services or for on-call emergency coverage, the regular physician or practice must address hospital privileging well in advance of the scheduled absence.

The physician or group engaging the substitute physician's services should be familiar with the hospital's credentialing process and the time it will take for the forms to be approved and for privileges to be granted to the locum tenens physician. For example, some hospital boards that approve credentialing decisions may only meet quarterly, making it difficult in some cases for the locum tenens physician to be granted privileges in the time frame required.

Therefore, it is extremely important that substitute coverage needs be coordinated well in advance. The regular physician should also notify hospitals of the name and contact information for any physicians who will be covering for him during his absence, as well as the exact dates of that coverage.

Some hospitals limit the duration of a locum tenens physician's access to the hospital, and may limit the rights of substitute physicians to renew such access, or they may require that the substitute physician receive direct written permission from the hospital to practice, even if the physician otherwise meets all credentialing requirements. Substitute or locum tenens physicians may be able to submit forms requesting temporary hospital privileges. They should keep copies of their written credentials on hand to send to hospitals with their request for privileges. Hospitals may also reserve the right to revoke such temporary privileges at any time.

Consider state rules

In addition to the common issues discussed above, there may be other considerations specific to particular states. For example, some states require that a locum tenens physician may not be a member of the same group in which the regular physician is a member. However, in Indiana, for example, if a physician is merely substituting for another physician in a reciprocal relationship, then the substitute physician may be part of the same group. An example of this would be a physician within a practice group treating a patient who requested unscheduled care that the regular physician cannot fit into her schedule.

Don't let an unplanned or poorly planned physician absence become a problem for your practice, patients, or reimbursement process. Every physician's practice should prospectively establish a substitute coverage policy before it is needed. Make sure that your policy identifies all applicable issues, including the ones described here, and that you have a standardized procedure to follow when a physician substitute is required.

Charlene McGinty is a partner and Sandra Herron is an associate in the Atlanta office of Powell, Goldstein, Frazer & Murphy, LLP. They practice in the firm's Health Care Group representing a broad and diverse client base, including physicians, physician practices, hospitals, suppliers, and manufacturers, on transactional and regulatory matters. Ms. McGinty may be reached at cmcginty@pgfm.com and Ms. Herron at sherron@pgfm.com, or both via editor@physicianspractice.com.

This article originally appeared in the September 2004 issue of Physicians Practice.