One of the objectives of on-site audits is to determine whether physicians’ patterns of practice for individual patients are justified.
One of the objectives of on-site audits is to determine whether physicians’ patterns of practice for individual patients are justified. In other words, is the number of services provided to a patient reasonable given their particular condition? If not, this could be perceived as overservicing your patients.
Audits have shown that in some cases of overservicing, chart reviews indicated that visits were occurring very frequently—weekly or every 2 weeks—over a long period of time with very little being done at each visit. Also, the visits may have been requested by the physician and not the patient. A normal follow-up frequency for patients with chronic diseases would be every 3 to 6 months, or every 2 to 3 months to review the status of their condition and to conduct a medication review and renewal, especially if supported by clinical guidelines. For acute conditions, a shorter duration between appointments may be reasonable, if medically necessary.
In addition to looking at patients’ charts, the Billing Integrity Program also looks at the physician’s practitioner profile (similar to the mini profile). Relating to overservicing, the program specifically reviews the number of services per patient receiving the service (S/PRS), the number of services per 100 total patients (S/100TP), and the diagnostic complexity score. A low or average comorbidity score associated with a high volume of services may be a concern.
A variety of factors affect the capacity of a practice, including the hours of work, the complexity of the patients, and the frequency of recalls. The efforts of practice support programs to attach more patients to GPs and foster advanced access models depend on a reasonable and justifiable frequency of visits. Physicians should be aware of the Preamble of the MSC Payment Schedule, specifically section C.5. Inclusive Services and Fees:
If it is not medically necessary for a patient to be personally reassessed prior to prescription renewal, specialty referral, release of diagnostic or laboratory results, etc., claims for these services must not be made to MSP regardless of whether or not a medical practitioner chooses to see his/her patients personally or speak with them via the telephone.
Seeing patients only as frequently as necessary, as long as that meets the standard of care, also helps to achieve the General Practice Services Committee and Practice Support Program goals of advanced access and more capacity to accept new patients.
—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 firstname.lastname@example.org.
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