Duties and responsibilities
Responding to a billing audit: How good records can help
Originally published in 1998 / Revised November 2017
An audit is most often triggered because a physician's billing profile is inconsistent with the average for the peer group, or a particular fee code is being used in a manner that does not meet a provincial or territorial billing agency’s or health ministry’s expectations. Provincial and territorial governments are obligated to ensure that physician billings comply with the federal Canada Health Act, and these governments may face penalties if irregularities are found.
An audit generally includes a review of the physician’s records, and the physician has an opportunity to respond to the concerns raised or demands for any proposed payback. The audit usually focuses on issues such as whether the service was performed, whether it was medically indicated, and whether the appropriate fee code was used. The audit may also determine the amount of the fees, if any, that need to be paid back by the physician.
Inadequate, missing, illegible or otherwise deficient record keeping often hinders physicians’ ability to effectively explain and defend their billings. For example, a psychiatrist’s billings were audited during which it was found that he did not document the start or end times for psychotherapy sessions. Without documentation supporting the length of each session, the audit resulted in a significant payback being demanded of the psychiatrist’s billings for psychotherapy sessions, despite the fact that he provided testimonials from patients, office staff, and colleagues that these services were rendered.
Physicians may want to employ these best practices to help justify their billings:
- Document the details of each patient encounter in the patient’s medical record at the time the service was provided.
- For timed procedures such as psychotherapy, counselling, and anaesthesia time units, include the start and stop times of the service or procedure in the record.
- Familiarize yourself and your staff with the schedule of benefits issued by the ministry of health in your province or territory. If you do not understand the fee code, obtain written clarification from the ministry of health and your provincial medical association, federation or society.
- Ensure billings correspond to the date that the services were rendered.
Contact the CMPA for more information, and to obtain assistance and advice about billing matters.