This is the fourth and final article in the series that takes you through what to expect if you are the subject of a billing audit by the Billing Integrity Program. This article covers phase 4: recovery.

The recovery phase commences when the Medical Services Commission approves a recommendation from the Audit and Inspection Committee to pursue recovery.

To begin, the Medical Services Commission advises the Legal Services Branch in the Ministry of Justice to pursue recovery, notifies the auditee that recovery is being pursued under Section 37 of the Medicare Protection Act, and notifies the College of Physicians and Surgeons of BC and Doctors of BC of the recovery action. A copy of the audit report is also provided to the auditee.

The Legal Services Branch then assigns a lawyer to the file, acknowledges they have received instructions to pursue recovery, and prepares all records pertinent to the file for legal disclosure, with assistance from the Billing Integrity Program.

The appointed legal counsel begins to correspond with the auditee, or his or her legal counsel, and advises them of the alternative dispute resolution process available. Most cases are settled through mediation, following further correspondence or face-to-face meetings, rather than proceeding to a formal hearing. However, if mediation is not sought or is not successful, a formal hearing is held.

If a settlement is reached, the appointed legal counsel drafts an agreement for signature by the Medical Services Commission and the auditee. A Pattern of Practice Order, requiring the auditee to abide by certain rules or restrictions, may also be implemented.

In exceptional circumstances when an intentional breach occurs, such as submission of claims knowing the claim was not rendered, deliberate misrepresentation of the nature and extent of the benefit rendered, or failure to comply with a Pattern of Practice Order or other Section 37 order, the Medical Services Commission may pursue action under Section 15 of the Medicare Protection Act. Typically these cases will go straight to a hearing and can result in physician de-enrollment. Certain cases are also referred to the police. 
—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This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board.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 [10].