Cross Coverage Contracts


Brighton, CO
Best answers
Our providers have contracted with physicians in other groups to establish an on call schedule. The contract includes information about who bills if one delivers another's patient. In addition to billing, we then pay the provider who "caught" the baby an amount that was agreed upon in the contract. I've worked for another OBGYN that had contracts like this. My question is what risk does this impose on us considering we are billing for a global delivery but didn't technically "catch" the baby.

Thank you,

It sounds like this is what is referred to as reciprocal billing arrangement. For Medicare purposes a reciprocal billing arrangement is:
* An agreement between providers to cover (on call) when the regular provider is unavailable
* The MAC may pay the patient’s regular physician for services provided to his/her patients by another physician on an occasional reciprocal basis.

How does the billing work?
* The regular physician submits the claim for the covered service under their NPI with a Q5 modifier
* Q5 Service furnished by a substitute physician under a reciprocal billing arrangement
* The regular physician will receive the payment
* The on call provider is paid per the physician agreement.

Medicare Reference:

The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:

• The regular physician is unavailable to provide the visit services;

• The Medicare patient has arranged or seeks to receive the visit services from the regular physician;

• The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days subject to the exception noted below; and

• The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering in item 24d of Form CMS-1500 HCPCS code Q5 modifier (service furnished by a substitute physician under a reciprocal billing arrangement) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering the unique physician identification number (UPIN) or NPI when required on the form and cross-referring the entry to the appropriate service line item(s) by number(s). Until further notice, the regular physician must keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s UPIN or NPI when required, and make this record available to the carrier upon request.

EXCEPTION: In accordance with section 116 of the “Medicare, Medicaid, and SCHIP Extension Act of 2007” (MMSE), enacted on December 29, 2007, the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces has been extended for services furnished from January 1, 2008 through June 30, 2008. Thus, under this law, a physician called to active duty may bill for substitute physician services furnished from January 1, 2008 through June 30, 2008 for longer than the 60-day limit.