Finding your substitute: How to cover your time off

Torn between responsibilities to his solo family practice in White Oak, Pa., and a desire to see his daughter compete in out-of-town figure skating events, Louis DiToppa, DO, had to come up with a game plan.

He had an informal arrangement with another solo practitioner to cover his hospital call when needed, but the deal didn't cover time off to watch his daughter skate. Without any partners or midlevel staffers with prescribing authority to step in during his absence, he decided to hire locum tenens physicians. He figured it would cost about $800 per day, or $4,000 per week, but the cost seemed well worth it.

"The cost is high but you have to weigh it against mental sanity and time off," said Dr. DiToppa. "My daughter is only going to be 11 for [a short] time.

"We're still running the office and there's still income coming into the office," he added.

Many physicians find themselves in similar predicaments. While larger practices can likely cover physician absences from within their own ranks, smaller groups and solo physicians often have to work hard to keep their practices active while they are out.

Typically those physicians have two options: They can reach an agreement with outside physicians to step in as needed or they can hire locum tenens physicians. The former scenario is most often used for short-term absences and might be as simple as a verbal understanding without any exchange of money. The latter, which may involve more advanced planning, is typically used to fill in for longer periods --absences of weeks or months -- and will likely require a contract as well as payment.

Either way, experts say physicians should make such decisions carefully to avoid legal or financial fallout and to ensure the best care for their patients. The first step, they say, is to allow plenty of time to research the options, if possible.

"The more lead time you have, the better chance you have for effectively finding an interim doctor or replacement doctor," said Ken Hertz, a senior consultant with the MGMA Health Care Consulting Group in Alexandria, La.

Allowing plenty of lead time will also help physicians determine precisely what their needs are. Hertz said this includes pinpointing the exact time for which the covering doctor's services will be needed and figuring out which clinical skills should be sought.

The departing physician should also determine whether the doctor filling in will be required to cover call, carry a pager or fulfill responsibilities beyond routine practice work. Any extra duties can increase costs and may determine whether locums are even an option, Hertz said.

Who are you going to call?

Of course some physicians may have no choice but to go the locum tenens route because it can be difficult to find another practice whose physicians are available and compatible.

"You don't want to do this with someone whose practice culture is different. If one practice is very compassionate and low key ... and the other is a [different] mind-set ... the patients probably won't be happy to see those doctors," said Hertz.

Finding a practice for such an arrangement may come down to word-of-mouth and luck. Experts say most of these deals are formed among physicians in the same community. Typically, the arrangement is reciprocal but often there is no formal contract spelling out its details.

"These are handshake understandings, agreements or pacts that are reached. Basically, [the agreements say] if the need arises, one or more of us will agree to serve your practice in a manner that allows you to keep things together," said Gray Tuttle, a health care consultant with The Rehmann Group in Lansing, Mich.

Tuttle said the physicians in both groups should be in the same geographic area so patients won't have to travel too far if they are seen in the offices of the covering physician. Also, the physicians should have privileges at the same hospitals so it will be easier for a returning doctor to follow-up on the care of any patients who were admitted during the absence.

Robert J. Freedman Jr., MD, a cardiologist in Alexandria, La., and his two partners have an informal agreement with a two-physician group across town. It started out as reciprocal call coverage but both groups liked it so well they now help each other out during absences.

"I was out for a month for surgery in November and everybody covered so it was no problem," Dr. Freedman said. "Had it only been the three of us and one was out it would have been much more stressful."

He said one of the reasons the arrangement has worked so well is the groups' compatibility. Before they started helping each other out, the groups sat down and went over various scenarios to get a sense of how certain situations would be handled. They also set expectations for each other. They wouldn't have gone forward if they hadn't felt comfortable.

"It's sort of like dating or marriage. If it works, it works, and if it doesn't, you try to find somebody else," Dr. Freedman said.

If no other physicians are available, or if the absence is going to be extended, it may be necessary to hire a locum tenens physician. Most physicians use a staffing firm that specializes in such placements. Some locum tenens physicians work independently, but Tuttle said it may be more difficult for them to fill staffing requests in a timely manner.

Physicians scouting out locum tenens firms should look at how long the firm has been in business, its financial stability and what type of liability insurance it uses to cover its physicians, said Trey Davis, executive vice president of Staff Care Inc., a locum tenens firm in Irving, Texas. He also suggested checking with state health agencies for endorsements and asking for references.

Some physicians seeking hard to find locum tenens physicians, such as certain subspecialists, may need to use one of the larger staffing firms, said Katie Abby, immediate past president of the National Assn. of Locum Tenens Organizations and chief operating officer of the locum tenens firm Vista Staffing Solutions in Salt Lake City.

"A lot of it is your comfort level with the person you're working with and that person's ability to fulfill your need," she said.

Abby said there likely won't be a minimum period for using the locum tenens physician. "You can basically request anything you want. [But] in general, a full week's worth of work is usually what's necessary to get a physician to block out his schedule for you."

What's it going to cost?

Staffing firms may be able to offer general pricing, but costs will vary with each situation, since the firm will have to locate a suitable physician for the assignment and adjust the fee to include any travel and/or lodging expenses.

Typically, prices are based on specialty, but may be adjusted for factors such as special qualifications. Staff Care, for example, said it generally charges $650 to $850 a day for family and internal medicine physicians, $2,000 to $2,500 for radiologists and $1,400 to $1,700 for anesthesiologists.

Hertz said physicians who are considering hiring locum tenens help should look at whether the daily fee will be offset by the practice revenue. After all, a visiting physician won't likely be able to see quite as many patients as the regular physician, who is familiar with their histories and the procedures of the office.

Tuttle said it may be expensive, but "at least some revenue is coming in. It keeps the staff employed and keeps the engine running."

The locum tenens firm will likely require that a contract is signed for the service. The contract may include clauses indicating cancellation penalties and prohibiting the physician client from using the locum tenens physician without the firm's involvement for a year or two.

Locum tenens physicians should have their own liability insurance. Charlene McGinty, a health care attorney with Powell Goldstein in Atlanta, said it is worthwhile to ask for proof. She said the locum tenens firm should be willing to provide a certificate of coverage from the insurance company spelling out exactly how much coverage is provided and indicating the terms of any tail coverage. Also, the firm should be able to affirm that the substituting physician is licensed and arrange any credentials needed to fulfill the obligations of the assignment.

Physicians who hire substitutes outside of staffing firms will likely have to double-check for licenses and arrange credentials themselves. And experts say that physicians who work out coverage arrangements with other practices should verify that such documents are current.

McGinty said it is also a good idea to ensure that the covering physician hasn't been excluded from participating in federal health programs. The Office of the Inspector General of the Dept. of Health and Human Services posts a list of such exclusions on its Web site (link).

Locum tenens physicians typically bill Medicare under the practice's name, using a special modifier. McGinty said this is allowed for up to 60 days. Managed care companies generally take the same approach, but it may be worthwhile to check with all payers to find out whether they have special procedures before the billing begins.

"You don't want to do this wrong and then try to double back and try to correct it," said Hertz.

Most experts recommend notifying patients before using a planned substitute. That may be as simple as informing patients with who have appointments during that period or posting a sign in the office.

"I always counsel physician clients that the more information you can give the patient, the less likely it is that there will be an issue with the arrangement," said McGinty.