Billing Integrity Program
The Billing Integrity Program provides audit services to the Medical Services Plan (MSP) and the Medical Services Commission (the Commission). The Commission is authorized to monitor the billing and payment of claims in order to manage expenditures for medical and health care benefits on behalf of MSP beneficiaries. The Billing Integrity Program monitors, audits and investigates billing patterns and practices of medical and health care practitioners to detect and deter inappropriate and incorrect billing of MSP claims. The Billing Integrity Program develops and analyses practitioner’s profiles, monitors trends, conducts audits, and in accordance with the legislation, where appropriate seeks recovery of inappropriately paid monies.
Carry out independent compliance audits and investigations for the commission to provide assurance to government and taxpayers that financial accountabilities are in place, to detect and deter abuse of MSP funding, and where necessary recover overpayments.
Detect, deter, recover ineligible payments to medical and health care practitioners, and enforce legislation that supports the sustainability of the MSP.
The Billing Integrity Program works closely with the Ministry of Justice in pursuing recovery of overpayments. The Billing Integrity Program monitors MSP payments and, in compliance with the legislation, routinely provides information and statistical data to various health regulatory bodies and associations.
The two main methods the program uses to monitor payments for services rendered by practitioners billing MSP on a fee-for-service basis are service verification audits and practitioner profile reviews.
Service Verification Audits
Random Service Verification Audits
Each year, up to 72,000 survey letters are sent to patients to confirm they received physician services, which have been billed to the MSP on their behalf. A minimum of 1,200 physicians (100 per month) are chosen annually (at random) and letters are sent to approximately 50 of their patients who have received MSP billed services in the preceding four months.
Select Service Verification Audits
A select service verification audit may be initiated due to findings from a random service verification audit, follow-up up of a previous audit, complaints received from the general public/other doctors/referrals by licensing bodies and professional associations, or by atypical practitioner billing profiles.
Letters may be sent to some of the selected practitioner’s patients to confirm they received the specific services that have been billed to MSP on their behalf.
Practitioner Profiles Reviews
A profile report is produced annually for each practitioner who receives fee-for-service payment from MSP. The profile is an analysis of the type and number of insured services that a practitioner has billed to MSP. Practitioners are divided into peer groups based on types of fees items billed. Standard deviations and medians are calculated based on the peer group. Each practitioner within an individual peer group is then compared against the group average statistics.
The practitioner profile provides an overview of the practitioner’s paid claims for services provided personally, and for claims submitted by other practitioners as a result of referrals. The profile is a summary of the patients, services, and costs associated with a practitioner in a calendar year (based on date of service). Rate-based measures (ratios of services or costs to patients) provide further indicators of service utilisation and billing patterns that take practice size into account. All claims associated with the whole population of patients seen by the practitioner are summarised.
A practitioner’s profile compares practice-specific data with group average data for the peer group. These comparisons show if the practitioner’s pattern of practice is within statistical norms for his/her peer group or outside of these norms. If the practitioner is outside of the norms for her/his peer group with respect to some aspect of service provision or billing a relative measure of “how far from the peer group norm” is provided. These relative measures are referred to as flags. The flags use standard deviations, quartile spreads, or percentile ranking of the practitioner’s statistics to measure the variation from the peer group average.
The data source for the practitioner profiles is all fee-for-service claims processed by the MSP Claims system in the previous calendar year. Included in the data are claims paid under the MSP budget and claims paid by MSP on behalf of ICBC and WCB. Payment data is also provided by the Alternative Payments Program, which funds physicians for salaried payments, sessional payments, and Service Agreements.
Medical Practitioners Mini Profiles
The practitioner profile is a large detailed analysis of each practitioner’s billings. A graphical representation of the detailed profile is produced for physicians by the Doctors of BC called the mini profiles. The mini profiles are made available by the Doctors of BC to all physicians billing MSP so that doctors can see if their billings are within the normal statistical boundaries of their peer group. This provides doctors with an opportunity to identify potential billing issues that may require corrective action.
Sources of cases for audit include significant irregularities identified in service verification audits, complaints from the general public or members of the profession, referrals from the licensing bodies and professional associations, issues identified by the claims adjudication area of MSP, and abnormalities present in practitioner profiles or other ad hoc data analyses.
An on-site audit involves an audit of clinical records, usually conducted at the site of the practice, thus referred to as an on-site audit. An on-site audit involves chart review by an inspector, who is a peer of the audited practitioner, and audit of the practitioner's business practices (relative to MSP billings) by an accountant.
The objectives of an audit include the review of clinical records and other materials to determine, whether a practitioner has:
(a) an unjustifiable departure from the patterns of practice or billing of practitioners in the practitioner's category;
(b) a claim for payment in respect of a benefit that was not rendered; or,
(c) misrepresented the nature or extent of benefits rendered.
The audit may include an appraisal of the clinical necessity for the frequency of visits observed and other factors included in the statutory objectives.
Each audit results in the submission of a detailed report to the Audit and Inspection Committee. Subsequently, the Audit and Inspection Committee makes recommendation to the Commission to assist the Commission in determining if recovery should be pursued. Practitioners have a right to be heard before the Commission makes a determination.
Health Care Practitioners
The Commission’s audit powers over health care practitioners have been delegated to various special committees. A special committee for each body of health care practitioners has been established. The special committees are: the Chiropractic Special Committee, the Dentistry Special Committee, the Massage Therapy Special Committee, the Naturopathy Special Committee, the Optometry Special Committee, the Physical Therapy Special Committee, the Podiatry Special Committee, the Acupuncture Special Committee and the Midwifery Special Committee.
Each audit results in the submission of a detailed report to the individual Special Committee. Subsequently, the individual Special Committee makes recommendation to the Health Care Practitioners Special Committee for Audit Hearings to assist the Health Care Practitioners Special Committee for Audit Hearings in determining if recovery should be pursued. Practitioners have a right to be heard before the Health Care Practitioners Special Committee for Audit Hearings makes a determination.
A hearing is held before a panel of three or more persons who are appointed by the Commission to represent the Doctors of BC, beneficiaries and government. A panel has authority to make an order for recovery of money and other remedies. The hearing affords the practitioner a fair process, adhering to the rules of natural justice. Panel decisions and reasons can be viewed by visiting the Commission webpage: http://www.gov.bc.ca/medicalservicescommission
Alternative Dispute Resolution Process
A discretionary alternative dispute resolution process allows the commission and practitioner the opportunity to reach a negotiated settlement. The alternative dispute resolution process can employ the use of a mediator for negotiation. In this way, a cooperative rather than adversarial process can be used to reach a fair and appropriate settlement reflective of particular circumstances.