Re: Why an audit? The audit process in BC explained

Issue: BCMJ, vol. 56, No. 2, March 2014, Page 80 Letters
By: Murray McFadden, MD,
Related To:

Why an audit? The audit process in BC explained

Thank you for explaining the BC audit process (BCMJ 2013;55:390-393).

Not mentioned in your article is the fact that Ontario has core audit values presuming physician innocence and fair process. Ontario emphasizes education and prevention, an initial claims review process, an independent physician payment review board (PPRB), and a joint committee on the schedule of benefits to provide its opinion on interpretation of the fee guide.[1] Ontario law changed in 2006[2] and 2010[3] as a result of Justice Cory’s report,[4] “Medical Audit Practice in Ontario.” That high-level and comprehensive 8-month inquiry was tragically the result of a physician suicide. Its 118 recommendations constitute the Gold Standard of Audit Integrity, and few of Justice Cory’s check-and-balance safeguards exist in BC. Ontario law limits the audit period to 19 months.[5]

BC considers the physician guilty before audit and employs a punitive 5-year penalty period. Sadly, BC’s Audit and Investigation Branch’s Mission is to: “Detect, Deter, and Recover… inappropriate claims/billings.”[6]

In the figure on page 391, item 8: “Preliminary error list…” red-lights the Billing Integrity Program’s bias of physician guilt before innocence! Item 1: “Review conducted by Billing Integrity Program” (BIP) confirms that the BIP authorizes the audit. This process carries no requirement of consultation with real peers who actually perform the service, the section who might bill the service, the BCMA Tariff Committee, and no requirement that the secret “new judgment/fee item interpretation or billing requirement” be disseminated to the profession. 

The Patterns of Practice Committee (POPC) has described the BC audit system. Now that we have taken a history, might we proceed to a physical examination, working diagnosis, and treatment? I remain hopeful that your plan to move from a description of “What IS” to “What OUGHT TO BE.” It would be disappointing to learn that your description is simply a defence for continuing POPC participation in a nonreformed, dysfunctional, and flawed process. All MDs agree on the need for audits, but the process must, of necessity for BC patients, the MSP, and MDs, actually have integrity.
—Murray McFadden, MD
Langley

References

1.    Physician Payment Review Board. The Physician Payment Review Board becomes functional. Ontario Bulletin 4511, 30 April 2010. Accessed 28 January 2014. www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4000/bul4511.pdf.
2.    Legislative Assembly of Ontario. Bill 171, An Act to improve health systems by amending or repealing various enactments and enacting certain Acts. 2007. Accessed 28 January 2014. www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=519.
3.    Ontario e-Laws. Schedule I, Physician Payment Review Process. Ontario Health Insurance Act. Queen’s Printer for Ontario. 2010. Accessed 28 January 2014. www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h06_e.htm#BK88.
4.    Medical Audit Practice in Ontario. Ministry Reports. Last modified 22 April 2005. www.health.gov.on.ca/en/common/ministry/publications/reports/cory05/cory....
5.    Ontario e-Laws. Section 18(12) Payment of Accounts: Limitation on when notice may be given. Ontario Health Insurance Act. Queen’s Printer for Ontario. 2010. Accessed 28 January 2014. http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h06_e....
6.    Audit and Investigations Branch. Enhancing the Audit Process. PowerPoint document presented at: Medical Services Commission meeting. 10 April 2013.

Murray McFadden, MD,. Re: Why an audit? The audit process in BC explained. BCMJ, Vol. 56, No. 2, March, 2014, Page(s) 80 - Letters.


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