By: Keith J. White, MD
Audit recovery and de-enrollment
Issue: BCMJ,
vol. 57, No. 2, March 2015,
Page 63 Billing Tips
You may have read previous articles pertaining to the audit process and recovery. It is important to be aware that in addition to audit recovery, the Medical Services Commission (MSC) can also order a Section 15 de-enrollment against a physician. What does this mean?
Section 15 of the Medicare Protection Act includes the following actions in the description of what constitutes cause (and grounds for de-enrollment):
(c) the submission of a claim by the practitioner to the commission for payment knowing that
(i) the benefit had not been rendered, or
(ii) the nature or extent of the benefit that was rendered had been misrepresented, and
(f) failure to comply with a written order [also referred to as a Patterns of Practice Order] made under Section 37(1)(e) to adopt an appropriate pattern of practice or billing.
De-enrollment does not mean a physician will lose his or her licence; it means the physician will be unable to bill the Medical Services Plan for a period of time determined by the MSC. The period of time can vary from as little as 1 month to a permanent de-enrollment.
Knowing and adhering to the MSC Payment Schedule and Preamble, as well as making and maintaining an adequate medical record of each patient encounter that appropriately supports the service being claimed, will save you in an audit and prevent de-enrollment.
If you have been audited before and have signed a Patterns of Practice Order, it is critically important that you comply with that order.
—Keith J. White, MD
Chair, Patterns of Practice Committee
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This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board.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, audit and billing advisor, Physician and External Affairs, at 604 638-2829 or jgrant@doctorsofbc.ca.