Locum Tenens Progress
By Alpha Lillstrom
June 6, 2016
The staffing challenges of a small private practice are familiar to many: If you are unavoidably absent from your practice, it is likely that you have insufficient staff to cover all of the Medicare patients you have on the schedule. Unlike many private payers who will accept a substitute therapist or locum tenens provider, Medicare does not allow physical therapists to bring in a qualified substitute to provide care in the absence of a physical therapist enrolled at that clinic location. Instead, you must cancel appointments—interrupting their care and your cash flow. If you want to use a visiting physical therapist, that individual must already be credentialed by Medicare for your specific practice.
There are times when a physical therapist must be out of the office for a short-term absence in circumstances ranging from an illness, family emergency, and vacation to continuing medical education or jury duty. Recognizing the importance of maintaining access to care, a locum tenens option has been a part of Medicare and available to physicians since the early days of the program. Now that physical therapy is fully recognized as part of a comprehensive care model, it is high time that patient access to physical therapy also receives the same protections against delays due to unavoidable absences by their standard provider. The Prevent Interruptions in Physical Therapy Act (HR 556/S.313) introduced by Representatives Gus Bilirakis (R-FL) and Ben Ray Luján (D-NM), and Senators Chuck Grassley (R-IA) and Bob Casey (D-PA), respectively, would improve access to care by allowing physical therapists to use the existing locum tenens provision.
Under current law1 physicians, osteopaths, dental surgeons, podiatrists, optometrists, and chiropractors can mitigate the effect of a short-term absence easily by entering into a locum tenens arrangement with a qualified substitute provider. Under these long-standing and widespread practice arrangements, the regular provider bills and receives payments under Medicare Part B for the locum tenens professional’s services, as if the regular provider had performed the services themselves. The locum tenens provider is compensated directly by the regular provider’s practice. The patient’s regular physician must keep a record of each service, along with the substitute physician’s national provider identifier (NPI).2 The substitute physician generally has no practice of her or his own and moves from area to area as needed.
In cases of anticipated leave, it is possible to hire a substitute. This is achieved by adding a Medicare-enrolled physical therapist to the practice’s Centers for Medicare & Medicaid (CMS) certification. However, such an arrangement is neither realistic nor feasible in an emergency or short-term situation. The process is lengthy, complicated, and time-consuming—taking two to three months under the best of circumstances and requiring an onsite visit that typically duplicates a visit to which the practice has already been subjected. Furthermore, the process could be required for each provider absence, since Medicare certification lapses if a physical therapist has no associated billing with a practice for a certain period of time. This unwieldy process is certainly a reason physicians and other Medicare providers are permitted to use locum tenens arrangements; physical therapists should be afforded the same option. HR 556/S.313 represents a low-cost technical legislative correction that simply adds physical therapists to the list of providers allowed to utilize locum tenens arrangements under Medicare (when all other conditions are met and within their same authorized scope of practice).
These arrangements are common and benefit patients and providers alike. With the help of their physical therapists, many seniors’ function and mobility is restored after an injury or medical procedure, enabling them to live independently with a higher quality of life. When utilizing a locum tenens, a provider is able to ensure that there is no lapse in their patients’ care and that appointments will not need to be delayed or rescheduled. Care interruptions are known to impede Medicare patients’ rehabilitation. If enacted as introduced, this legislation would enable unfettered access care for physical therapy patients and thereby foster continued progress and positive outcomes. Recognizing the importance of maintaining uninterrupted access to care, in December 2014, the Private Practice Section (PPS) Government Affairs Committee and Board of Directors once again identified the passage of the locum tenens bill as a top legislative priority for the PPS. We are closer with this Congress than we have ever been.
Progress made during the 114th Congress
The Prevent Interruptions in Physical Therapy Act (HR 556/S.313) as introduced would enable all physical therapists, regardless of location and practice size, to use the existing locum tenens provision in Medicare.
In June 2015, the Senate Finance Committee passed an amended version of the Prevent Interruptions in Physical Therapy Act (S.313) that was limited to those physical therapists practicing in rural (non-Metropolitan Statistical Areas [MSAs]) as well as designated Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs). This decision to limit the scope of the bill was done solely for cost, not policy reasons.
We have long held that the need for locum tenens in physical therapy is not about the location of a practice but rather the size of the practice at which the Medicare patient chooses to receive treatment. In pursuit of passing a bill that focuses on the needs of the beneficiary, we have been working with the offices of Representatives Bilirakis and Luján as well as the Energy and Commerce Health Subcommittee staff to ensure that the bill that passes the House will be more inclusive and truly address the needs of all physical therapists and their patients.
The sponsors of the House bill requested more information describing the size, type, and location of practices affected by this gap in Medicare policy. PPS teamed up with the American Physical Therapy Association (APTA) and developed a seven-question survey for PPS members to shed light on the need for locum tenens in all communities, not just in the rural areas of the United States. The survey was sent to the 4,133 members of the Private Practice Section. In order to prevent duplication and distortion of results, the instructions asked that only one member (owner preferred) respond for each group of clinics in a practice. Over the course of a single week, a robust 467 members responded. The results clearly showed that physical therapists need to be able to utilize locum tenens in order for their Medicare beneficiary patients to maintain continued access to care. The survey revealed that a policy limiting utilization to rural and medically underserved areas would not solve the problem for the majority of physical therapists. At the same time, should Congress need to formulate legislation by clinic size for scoring purposes, the results of the survey can guide them to the proper and necessary therapist threshold.
There were a number of notable findings that we shared with members of Congress and their staff. First, nearly 70 percent of physical therapy clinics reported being located in urban or suburban areas, underscoring the fact that locum tenens is not solely a rural issue. Due to their location, more than two-thirds of physical therapy clinics would not be able to use locum tenens under the Senate’s amended version of the legislation. Moreover, more than 76 percent of physical therapy practices have only one or two clinic locations. This makes it difficult, if not impossible, for them to use their own staff to cover for the absence of a fellow physical therapist.
In question four of the survey, we asked respondents to report the number of Medicare-enrolled physical therapists at each clinic location. In order to facilitate more accurate results, the therapists reported separately for each of the clinics in their practice. Again, the results showed the prevalence of a small number of clinics in a given practice group—80 to 90 percent of clinics have five or fewer physical therapists enrolled in Medicare and providing care per practice location. Most clinics only enroll the physical therapists who are actually working in the clinic. In order to avoid interrupting the care of their patients, those clinics would need to use locum tenens when an unavoidable or unscheduled absence arises as they have no “extra” physical therapists to fill in.
In addition to sharing the survey results with the Energy and Commerce Health Subcommittee staff, we pointed out that the findings of this research support the need for passage of HR 556 as introduced. We made it clear that members of PPS feel strongly that a technical fix allowing all physical therapists to utilize the locum tenens provision would be appropriate for doctoral-level trained providers who are an integral part of the health care system for seniors. If your legislator sits on the House Energy and Commerce Committee, please reinforce this point when you reach out to share these findings and arguments in favor of extending locum tenens to physical therapists.
Acknowledging the reality of budget concerns, we pointed out that should the cost of HR 556 be an issue, the survey data could be used to inform the discussion. While our survey shows that a practice-size limitation could be a workable alternative, it also made it clear that the threshold number could be no lower than five or fewer Medicare-enrolled physical therapists per clinic location. Using the PPS survey data, Rep. Bilirakis has proposed an alternative that would make the locum tenens provision available only for outpatient physical therapy services provided in clinics with seven or fewer Medicare-enrolled physical therapists.
Clearly locum tenens is not exclusively a rural issue; therefore, we remain committed to a policy that provides access to private practice physical therapists practicing nationwide. At its core, the need for locum tenens in physical therapy is a beneficiary issue, not about the location but rather the ability of a practice to mitigate the effect of unexpected absences. Without locum tenens, small practices do not have the resources or capability to employ the number of therapists on staff that will ensure uninterrupted care to their Medicare patients. It is incomplete policy to allow the rural (non-MSAs), MUAs, or HPSA-located practices to use locum tenens while a similarly sized practice located elsewhere is not allowed to do so—the impact of interrupted care is the same regardless of geographic location or population density.
Because this is an election year, the short legislative calendar presents serious challenges to passing legislation even when it has bipartisan support. Nevertheless, there is strong interest in the House to move this bill forward. In addition to our work here in Washington, D.C., your voices as concerned practitioners advocating for increased cosponsorship of the bill could make a big difference toward realizing that goal. PPS Key Contacts lobbied on behalf of the Prevent Interruptions in Physical Therapy Act (HR 556/S.313) during their targeted Hill day on April 5. As a result of the in-person advocacy during the fly-in, 10 Representatives joined as cosponsors. As of this writing, the bill has 95 House and 28 Senate cosponsors. There is a clear pattern of increased cosponsorship when PPS members reach out to their Representatives and Senators asking for their support. If your member is not already a cosponsor, find your Representative here and find your Senator here and reach out today. Together we can work to achieve passage of a locum tenens policy that will meet the needs of your patients, your practice, and the private practice physical therapist community.
1 (42 U.S.C. 1395u(b)(6)). The process under Section 1842(b)(6) of the Social Security statute: The patient’s physician of record may submit a claim and (if assignment is accepted) receive the Part B payment for covered visit of a locum tenens physician who is not an employee of the regular physician and whose services for patients of the regular physician are not restricted to the regular physician’s offices, if the following conditions are met: 1) the regular physician is unavailable to provide the visit services; 2) the Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician; 3) the regular physician pays the locum tenens for services on a per diem or similar fee-for-time basis; 4) the substitute physician does not provide the visit services to Medicare patients over a continuous period of more than 60 days, and 5) the regular physician identifies the services as substitute physician services by entering the HCPCS modifier Q6 (service furnished by a locum tenens physician) after the procedure code in Item 24d on the CMS-1500 claim form or electronic equivalent. The physician and practice of record bills and receives payment for the substitute clinician’s services as if he/she performed them him/herself.
2 Before June 2007, it was required that the records contain the unique physician identification number (UPIN). The UPIN was discontinued and replaced by the NPI at that time. https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/UniquePhysicianIdentificationDirectory.html
Alpha Lillstrom is a registered federal lobbyist working with Connolly Strategies & Initiatives, which has been retained by PPS. An attorney by training, she provides guidance to companies, nonprofit organizations, and political campaigns. For six years, she served as Senior Policy Advisor and Counsel for Health, Judiciary, and Education issues for Senator Jon Tester (Montana), advising and contributing to the development of the Affordable Care Act, as well as working on issues of election law, privacy, government transparency, and accountability. Alpha has also directed Voter Protection efforts for Senators Bob Casey, Al Franken, Russ Feingold, and Mark Begich. She was Senator Franken’s Policy Director during his first campaign and was hand-picked to be the Recount Director for his eventual 312-vote win in 2009.