Billing Integrity Program

»  Monitoring Activities
»  Case Finding
»  On-Site Audits
»  Audit Hearings
»  Alternative Dispute Resolution Process

The Billing Integrity Program (BIP) provides audit services to the Medical Services Plan (MSP) and the Medical Services Commission (MSC). The MSC is authorized and obligated to monitor the billing and payment of claims in order to manage expenditures for medical and health care on behalf of MSP beneficiaries. Audit of practitioner billings is a recognized utilization management and cost-saving activity that is supported by the B.C. Medical Association and respective health care associations for chiropractic, physical therapy, massage therapy, podiatry, dentistry, naturopathy and optometry.

Acting in the public interest and in the interest of most practitioners who bill MSP appropriately, BIP monitors and investigates billing patterns and practices of medical and health care practitioners to detect and deter inappropriate and incorrect billing of MSP claims. In cooperation with the professions, BIP develops and applies monitoring, case finding and audit criteria, and recovers inappropriately paid monies.

Monitoring Activities

Under the Senior Manager of BIP, a staff of medical consultants, research analysts and a team of auditors work closely with the Ministry of Attorney General, ICBC, WCB and the Royal Canadian Mounted Police. BIP monitors MSP payments and routinely provides utilization information and statistical data to various health regulatory bodies and associations.

The two main methods BIP employs to monitor payments for services rendered by practitioners billing MSP on a fee-for-service basis are:

Service Verification Audits - Each year, approximately 75,000 survey letters are sent to beneficiaries (patients) to confirm that they received services which have been billed to MSP on their behalf.

Practitioner Profiles - A profile report is produced annually for each practitioner who receives fee-for-service payment from MSP. The profile is an analysis of the type and number of insured services that a practitioner has billed to MSP. Practitioners are divided into peer groups based on registered specialties, and group averages (standard deviations, medians) are calculated based on the peer group. Each practitioner within an individual peer group is then compared against the group average statistics.

Case Finding

Sources of cases for investigation include significant irregularities present in service verification audits, complaints from the general public or other members of the profession, referrals from the licensing bodies and professional associations, issues identified by the claims adjudication area of MSP, and abnormalities present in practitioner profiles or other ad hoc data analyses.

Profiles use a combination of indicators or measures for comparing a practitioner with a peer group. The review is used to identify patterns of practice or billing which are significantly different from the average of the peer group. Exception limits are one tool used to focus investigative resources on practices where misbilling or overservicing are more likely to be found. Investigation normally focuses on two areas of inappropriate billing:

Overservicing - rendering more services than are clinically required.

Misbilling - substitution of fee items, usually a higher priced item, not consistent with the actual service rendered.

On-Site Audits

BIP may undertake an investigation of an unexplained variation by doing an on-site audit. An investigation involves an audit of clinical records, usually conducted at the site of the practice, thus referred to as on-site. An on-site audit involves chart review by an inspector, who is a peer of the affected practitioner, and audit of the practitioner's business practices (relative to MSP billings) by an accountant.

The objectives of the audit are to determine, based on the clinical record, whether a service was:

• actually rendered
• a benefit of MSP
• billed correctly
• medically necessary
• properly documented
• rendered by the practitioner making the claim, and
• performed in such a way that there are no quality of care concerns

The practitioner inspector may also give an appraisal of the clinical necessity for the frequency of visits observed. Each audit results in the submission of a detailed report to the MSC. If there are reasons to consider recovering funds that may have been paid inappropriately, the practitioner is given the opportunity to have a hearing before an Audit Hearing Panel prior to any order for recovery being made.

Audit Hearings

The Audit Hearing Panel includes representatives of the government, the profession and the public. It is a quasi-judicial body that has authority to make an order for recovery. Orders for recovery are filed with the B.C. Supreme Court. The hearing affords the practitioner a fair process, adhering to the rules of natural justice.

Alternative Dispute Resolution Process

The Alternative Dispute Resolution (ADR) process allows for reaching a negotiated settlement of disputes between practitioners and MSP. The ADR process employs both unassisted and assisted (the use of a mediator) negotiation. In this way, a cooperative rather than adversarial process can be used to reach a fair and appropriate settlement with less financial, psychological and procedural stress.

If you would like more information regarding the monitoring and investigation of billing patterns of practitioners or you wish to register a complaint, contact BIP.

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