Locum Tenens Risk Management Tips

The MICA Risk Team regularly consults with MICA physicians who need guidance about hiring locum tenens and risk management strategies to address liability concerns. When life calls, physicians sometimes must be away from their practice for an extended period of time. Reasons for these absences are varied and might include vacations, illness, family emergencies, international volunteer opportunities, or a death or birth in the family.  

Especially for solo and small medical practices, one of the biggest concerns in these situations is who will provide care for patients during the physician’s absence. Whether the absence will be for 2 weeks, a month, or even 60 days, sometimes the solution is a locum tenens. A locum tenens is a physician who provides patient care on your behalf during your absence. In this article, we summarize the guidance that our Risk Consultants offer MICA members on a regular basis concerning risk reduction when hiring locums. 

Coverage for Locum Tenens Under Your MICA Policy 

The MICA policy may provide up to 90 days of medical professional liability coverage for a locum tenens working on behalf of a MICA insured.¹ Under the terms of the MICA policy, coverage is only available when the locum tenens: 

• Holds an unrestricted license to practice in the same state as the insured while working on the insured’s behalf;
   
• Practices in the same specialty for which the insured is covered under the policy; and 
  
  
• IS NOT covered by any other available insurance.²

For coverage to apply, the MICA insured must maintain accurate records identifying the locum tenens and specifying the dates he/she worked on the insured’s behalf. 

At any time that the policy provides coverage for a locum working on the insured’s behalf, there will not be coverage for professional services provided by the insured on the same date. 

BEFORE YOU HIRE – A Checklist to Minimize Risk  

When you need someone to temporarily fill your shoes, a locum physician can be a great solution. To minimize risk, however, you should carefully screen potential candidates. Consider implementing the hiring checklist below.  

• Confirm licensing status. Hire only candidates who have an unrestricted license in the state where the absent physician practices.  
   
• Confirm specialty. For insurance coverage purposes and to minimize medical professional liability risk, select a locum practicing in the same specialty as the absent physician.
   
• Verify credentials and certifications. Confirm that candidates’ certifications are up to date and credentials are authentic. This might involve background checks, verification of past and present privileges, and confirmation of DEA registration and board certifications.
   
• Assess skills, training, and experience. To minimize liability and foster patient trust, locums you hire should be a good fit for your practice. Do they have the training and experience necessary to care for your patient population? Have they managed a case load comparable to yours? You and the locum should be on the same page about what to expect from a typical day or week in your practice.
   
• Confirm the candidate is not excluded from participation in federal health care programs. The U.S. Health and Human Services Office of Inspector General maintains this List of Excluded Individuals/Entities. To avoid potential civil monetary penalty liability, medical practices should routinely check the list to ensure that new hires and current employees are not on it.
   
• Verify the locum’s NPI. 
   
• Understand payor requirements for billing locum services. Although Medicare does not require locum enrollment, other payors may have different requirements. Prior to hiring, medical practices should understand their payors’ rules governing reimbursement for locum tenens services.
   
• Know how long you need locum coverage. Planning ahead based on how long the physician will be absent is important for insurance and billing purposes. Locum coverage under the MICA policy is only available for 90 days. 

CMS allows reimbursement for services provided by a locum when a claim is submitted under the absent physician’s NPI, provided the substitute physician does not render care to patients for more than 60 continuous days.³ Other payors may follow the same rule. Practices that need a locum for more than 60 days would likely need to credential the locum with their payors.  

• Assess malpractice insurance coverage. Does the locum have his/her own policy, or will you depend on coverage provided by the MICA policy as discussed above? If the locum has a separate policy, obtain a certificate of insurance to confirm.
   
• Document. Once you find a suitable candidate, create a personnel file to house the documentation you gathered during the hiring process. Consider maintaining this file for 10 years. In the event of a lawsuit involving allegations of negligent care by the locum, strong documentation may help you defend a negligent hiring claim. 

AFTER THE LOCUM ARRIVES – Risk Reduction Strategies 

Provide a Thorough Orientation 

Orient the locum to your practice environment and operations before he/she begins seeing patients. Develop a written curriculum that you can use for onboarding anytime you hire a locum. Include the following topics: 

• Instructions for navigating and using the medical records system;
  
  
• Documentation expectations;
  
  
• Processes for ordering tests and tracking results;
  
  
• Referral procedures;
  
  
• Emergency protocols; and
  
  
• Facility tour. 

As part of locum orientation procedures, designate a resource person who will be available to the locum for any questions and concerns. Consider having the locum meet weekly with that person to discuss any issues and ensure that the locum is fulfilling documentation expectations. 

Consider Communicating the Physician’s Absence to Patients 

Communication is essential for fostering solid physician-patient relationships. Patients who call to schedule an appointment may be surprised by the physician’s absence and reluctant to see the substitute. Most patients will appreciate your efforts if you take the time to notify them in advance.   

Tell patients during appointments or while on the phone. Consider posting notices in the office and on the website or portal. The notices could also include some information about the locum, just like bios you post on your website about practice physicians. 

Comply with Payor Requirements When Billing Locum Services 

When billing locum services, it is important to consult your payors to understand individual rules and requirements. Some payors, but not all, may follow CMS rules. 

Under Medicare rules:  

• Absent physicians may use modifier Q6 to bill and receive payment for locum tenens services as though the absent physician provided the care. 
   
• Medicare has dispensed with the term “locum tenens.” It now uses “fee-for-service compensation arrangements” to reflect that the “regular” physician (i.e., the absent physician) is paying the substitute physician on a per diem or other fee-for-time basis.
   
• Billing the services of non-physician practitioners like CRNAs, NPs, and PAs under fee-for-time compensation arrangements is not permitted. 

When billing using modifier Q6, the regular (absent) physician submits a claim using his/her own NPI. By using Q6, the regular physician certifies as follows: 

• The regular physician is unavailable to provide visit/services. 
  
  
• The Medicare patient sought or scheduled care with the regular physician. 
  
  
• The regular physician is paying the fee-for-time compensation arrangement physician (the locum) for his/her services on a per diem or similar fee-for-time basis.
  
  
• The substitute physician is not providing services to patients over a continuous period of more than 60 days. 

Medicare requires regular physicians who bill using Q6 to maintain a record of the substitute physician’s NPI and document each service the substitute provides. Although this information does not need to be submitted with the claim, it must be available to Medicare upon request. MICA recommends keeping these records for 10 years. 

More information about billing Medicare for fee-for-service compensation arrangements is available from Medicare Administrative Contractor Noridian in this link.  

Maintain Necessary Documentation 

When hiring locum tenens physicians, you should maintain records regarding the following: 

• Dates the locum provided care to patients;
   
• Documentation gathered during the pre-hiring and vetting process discussed above;
   
• The locum’s NPI;
   
• Care provided by the locum; and
   
• Complaints received from patients or others about the locum and details of any practice investigations of those complaints. 

MICA recommends keeping these records for 10 years. 

Our Risk Team is available to answer your questions. You can reach a Risk Consultant Monday – Friday 8:30am – 5pm MST at 800-352-0402 x 2137, 602-808-2137, or rm_info@micainsurance.com.

^{[1] Coverage is subject to limitations, restrictions, and claims and occurrence reporting requirements.}

^{[2] No locum tenens who is covered by any other available insurance, a self-insurance plan, self-insured trust, fronting self-insurance plan, and/or retrospective premium policy, or any similar source of payment or indemnification qualifies for coverage under the MICA policy.}

^{[3] There is an exception when a physician is absent for more than 60 days because of active military duty.}