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Nonperforming Physician Billing as Performing Physician.



     The OIG issued a fraud alert regarding multiple allegations of potential billing violations and fraud, including the following:



  • Filing claims as the performing physician in multiple states on the same dates.


  • Utilizing the services of locum tenens physicians who list the owning physician as the performing physician.


  • Not using the required Q6 modifier to indicate services performed by a locum tenens physician.


  • Locum tenens billing records were not available, making it impossible to determine who really performed the services.


  • Locum tenens physicians were used for longer than 60-day periods, a violation of the locum tenens provision.


     In addition, unqualified personnel were alleged to be performing tests on beneficiaries, including one case in which an emergency medical technician performed the services. 


Locum Tenens: It is a long-standing and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physician (defined as a physician normally scheduled to see the patient, including physician specialists) are absent for reasons such as illness, pregnancy, vacation or continuing education, and for the regular physician to bill and receive payment for the substitute physician’s services as though he or she performed them himself or herself.  The substitute physician generally has no practice of his or her own and moves from area to area as needed.  The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than that of an employee.  These substitute physicians are generally called “locum tenens” physicians.