Billing investigations

Originally published April 2002 / Reviewed July 2013

Members are eligible to receive CMPA assistance with billing reviews conducted by provincial and territorial paying agencies.

When appropriate, the CMPA retains legal counsel or experts of its choosing, and pays their fees and expenses. All fines, penalties, costs, or recoveries are paid by the member.

While assistance normally extends up until the end of the review process, from time to time the CMPA exercises its discretion and, if the circumstances warrant, instructs legal counsel to appeal the decision of the paying agencies. Examples of exceptions include when review committees commit a fundamental error in law, or obviously misinterpret the schedule of benefits.

Audits typically involve a review of the physician's records to determine whether the requirements of the schedule of benefits for that particular fee code have been met, and whether the service rendered was medically necessary. It is important to the defence of members that their records be complete, thorough, and accurately reflect their patient care.