This is the second article in a series of four that takes you through what to expect if you are the subject of a billing audit by the Billing Integrity Program. In the September article the pre-audit and planning phase of the audit process was outlined. This article covers phase 2, the on-site audit.
You are about to step out the door when a courier arrives with the initial audit notice from the Audit and Inspection Committee (AIC). Now what?
Typically, the Billing Integrity Program (BIP) will work with the auditee to determine a suitable date for the on-site audit to take place. The BIP makes every effort to minimize the disruption and allow the physician to carry on with a near-regular practice. On average, an on-site audit will take place over 3 or 4 days.
The audit team will be composed of two or three members--a medical inspector in the same specialty as the auditee, and one or two BIP senior auditors. Once the dates of the audit are agreed upon and the audit team has been assigned, the auditee will receive a letter from the BIP confirming the arrangements that have been made and identifying the audit team. The letter may also contain information on the concerns that led to the referral to the AIC.
The audit team will meet with the auditee prior to starting the audit and provide a list of patient files to be reviewed. All documentation related to the audit sample will be scanned.
The medical inspector will examine the clinical records to determine if they support the MSP billings and complete the necessary working papers.
The senior auditor will examine MSP and private billing procedures and claims records and may also interview other staff members.
On the last day of the on-site audit, the senior auditor and the medical inspector will conduct an exit interview to provide feedback and discuss preliminary findings with the auditee.
During the on-site audit the audit team will be reviewing whether:
1. Clinical records exist to support that services were rendered for the dates of service that claims were paid.
2. Complete and legible clinical records were maintained by the medical practitioner.
3. Services rendered were benefits under the Medicare Protection Act.
4. Fee items claimed were consistent with the services described in the clinical records.
5. Services claimed were provided by the practitioner.
6. Services claimed did not overlap with alternate payment arrangements.
7. Beneficiaries were not extra billed for benefits under the Medicare Protection Act.
8. Potential quality-of-care concerns exist (concerns are referred to the College of Physicians and Surgeons of BC).
9. Patterns of practice or billing (including service frequency) were justifiable.
What not to do
If you receive notification of an on-site audit
- Do not grab a pen and go through your records to add clarity.
- Do not go into your EMR and tweak the records.
Once the audit process is underway, the Patterns of Practice Committee cannot share any information with the auditee about the audit. Any concerns about the audit or the audit process should be addressed once the audit is complete.
If you have been through an audit, visit the Billing and Audits section under the Resource Centre tab on the Doctors of BC website (login required) to complete the Post-Audit Survey and provide us with some feedback (www.doctorsofbc.ca/resource-centre/physicians/billing-audits).
The next phase of the audit process is reporting. Watch for the next article in this series in the November BCMJ.
--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.