Avoiding an Audit

Being audited is an overwhelming and stressful time in a physician’s life. You can take steps to help reduce your risk of being audited.

Approximately 103 million claims or more are processed by the Medical Services Plan (MSP) annually, most of which are completed without pre-approval. This is because the system is built on trust and designed to pay. It also means that physicians who bill incorrectly may do so for years, not realizing their error until an audit occurs. Therefore, it’s essential to ensure that you meet your obligations to:

• meet the MSC payment schedules requirements of all fee items you are billing and
• make and maintain adequate medical records as specified in the poreambles and MSC payment schedules.

These tips may reduce your risk of triggering an audit and decrease the likelihood of a bad outcome if you are audited:

• Review an audit tool produced annually: Your mini practice profile.
• Do not rely on MSP to tell you that you billed incorrectly. Just because you billed for it and were paid does not mean you billed correctly.
• Take the time to document the services billed in the patient’s medical record.
• Read the preambles to the MSC payment schedules and your section of the Doctors of BC fee guide.
• Ensure all lab or diagnostic tests you order are medically necessary.
• Look at your remittances twice a month. If something looks wrong, contact MSP billing support at 1 866 456-6950.
• Suppose you receive advice from MSP billing support; document who, what, and when.
• Be cautious about relying on billing advice from colleagues and private pay companies.

Billing MSP for your services is a complex process. The following are some helpful billing and audit resources stemming from the most common errors revealed during on-site audits. 

Tips

The Billing Tips article series in the BC Medical Journal provides information on the most common errors discovered during billing audits.

Educational billing and audit resources

• The Doctors of BC fee guide is updated regularly and lists the services insured by MSP. It also provides recommended private fees for non-MSP-insured services. Please refer to the guide’s preamble for information on interpreting insured services.
• The Family Practice Services Committee’s billing guide includes incentive payments available to BC’s eligible family physicians.
• The Specialist Services Committee (SSC) fees are processed through the Medical Services Plan but are managed by the SSC.
• Longitudinal Family Physician (LFP) Payment Model and Medical Services Commission (MSC) Longitudinal Family Physician payment schedule.
• The Ministry of Health has developed a medical office assistant billing guide to assist physicians and office staff. The reference tool provides billing advice and examples on some of the most common MSP billing scenarios.
• The Reference Committee assists physicians in MSP billing disputes and is the last step in the MSP appeal process.
• Your Mini Practice Profile is an audit tool for all physicians who bill from the MSC payment schedules. It helps monitor their billing patterns in comparison to their peer group and provides valuable information that allows physicians to reflect on whether their billing patterns are justified in the event of a billing audit.