Am I being audited? Service verification audits versus on-site audits
The Billing Integrity Program (BIP) uses two main methods to monitor payments for services rendered by practitioners who bill MSP on a fee-for-service basis: service verification audits (SVAs) and practitioner profile reviews.
The Billing Integrity Program (BIP) uses two main methods to monitor payments for services rendered by practitioners who bill MSP on a fee-for-service basis: service verification audits (SVAs) and practitioner profile reviews. This article focuses on SVAs and the fundamental differences between SVAs and on-site audits.
SVAs versus on-site audits
The majority of SVAs serve to confirm, directly with a practitioner’s patients, whether a service was provided (there is no direct cost recovery involved). In an on-site audit, a medical inspector attends a practitioner’s office and examines the medical records to determine if they support the MSP billings (there may be a cost recovery).
The Service Verification Group will inform a practitioner that letters have been sent to their patients for the purpose of an SVA (this should not be confused with notification of an on-site audit). Depending on the results of an SVA, a further review of a practitioner’s billings may be conducted by the BIP. If there are concerns with an SVA, the Service Verification Group may send the practitioner a letter asking for medical records, which may help to explain the comments received from their patients.
Each year up to 60 000 survey letters are sent to patients to confirm that they received the services that have been billed to MSP on their behalf. Up to 1200 practitioners are chosen annually (at random) and letters are sent to 50 of their patients who have received MSP-billed services in the preceding 4 months.
Most random audits have very few material findings. Random audits serve as a routine monitoring and control measure. They may also identify some inappropriate billing patterns, which may not necessarily have been recognized otherwise.
A select SVA may be done to follow up on findings from a random audit, complaints received (which may be from the general public, colleagues, licensing bodies, or professional associations), or atypical billing patterns or practice profiles.
Letters are 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. This is done much less frequently, and letters are sent to 100 to 200 patients who have received MSP-billed services in the preceding 6 months.
—Lorne Verhulst, MD
Chair, Patterns of Practice Committee
This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, manager, audit and billing, Physician and External Affairs, at 604 638-2829 or email@example.com.
Lorne Verhulst, MD. Am I being audited? Service verification audits versus on-site audits. BCMJ, Vol. 59, No. 7, September, 2017, Page(s) 379 - Billing Tips.
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