This is the first of four articles in a series that will take you through what to expect if you are the subject of a billing audit by the Billing Integrity Program.
Being audited, whether by Revenue Canada or the Billing Integrity Program, can be overwhelming. If you are audited your first thoughts are likely to be why am I being audited and what happens now?
The first phase of the audit process (the pre-audit and planning phase) begins with a review of a practitioner’s practice. Reviews are initiated by various triggers, including service verification audits (random patient confirmation), tips or complaints, and results of fee analysis projects and statistical analysis. The Billing Integrity Program medical consultant conducts a review of the practitioner’s billings from the last 2 to 3 years and looks at the results in various ways—billings by day, by fee item, by patient, and by diagnosis. The consultant will also look at the practitioner’s profile.
If, after completing the review, the Billing Integrity Program determines that there is enough concern to warrant an on-site audit, the practitioner is referred to the Audit and Inspection Committee. Audits are never conducted solely on the basis of a tip or complaint.
When a practitioner is referred to the Audit and Inspection Committee, the following actions take place:
1. The Audit and Inspection Committee reviews all pertinent information provided by the Billing Integrity Program and approves or rejects the referral. The Medical Services Commission has delegated the responsibility of determining which practitioners should be audited to the Audit and Inspection Committee. The committee is composed of three physicians and a member of the public. The physicians represent Doctors of BC, the College of Physicians and Surgeons, and the provincial government.
2. If the Audit and Inspection Committee approves the referral for audit, the committee notifies the practitioner in writing that an audit of his or her practice has been authorized. If there are certain concerns the Audit and Inspection Committee may authorize a “no-notice” audit.
3. The Billing Integrity Program, which conducts the on-site audit, contacts the practitioner to arrange for the audit to take place.
4. The Billing Integrity Program notifies the practitioner in writing of the audit date, who the audit team members are, and other specifics.
5. The Billing Integrity Program prepares for the on-site audit and requests data and records, as required, from the practitioner.
If you receive notice of an audit, contact the Canadian Medical Protective Association immediately. They will put you in touch with a legal firm that will assist you in the process. You can also speak with Ms Juanita Grant, audit and billing advisor at Doctors of BC, who will answer your questions and bring any concerns to the attention of the Audit and Inspection Committee. If you are feeling overwhelmed, you should also contact the Physician Health Program. You do not have to go through this process alone.
Watch for the second article in this series in the October BCMJ, where we will describe the next phase—the on-site audit.
—Keith J. White, 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, audit and billing advisor, Physician and External Affairs, at 604 638-2829 or email@example.com.
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
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