Audits explained

While most physicians go their entire careers without being subjected to an audit, if it does occur, it can be a stressful, disruptive, and overwhelming experience.

Business Pathways has developed a list of different kinds of audits to guide doctors through the process and direct them to valuable resources and supports.

Billing audit

The Medical Services Plan (MSP) fee-for-service system requires that physicians bill appropriately for services provided, and is based largely on trust. 

The Medicare Protection Act provides the Medical Services Commission (MSC) with the legislated authority to audit physicians and allied health care practitioners in BC. The Billing Integrity Program (BIP) provides audit services to the Medical Services Plan (MSP) and the MSC. MSC is authorized to monitor the billing and payment of claims in order to manage expenditures for medical and health care benefits on behalf of MSP beneficiaries.

The mandate of the Billing Integrity Program is to carry out independent compliance audits and investigations for MSC to provide assurance to government and taxpayers that financial accountabilities are in place, to detect and deter abuse of MSP funding, and where necessary, recover over-payments. Methods used in the program to monitor payments for services rendered by physicians billing MSP on a fee-for-service basis are service verification audits, either a random service verification audit or a select service verification audit, and practitioner profile reviews. 

The Audit and Inspection Committee (AIC) is responsible for the auditing and inspection of the practices of medical practitioners and has been delegated the powers and duties of the MSC under the Act.

The Patterns of Practice Committee (POPC), an Advisory Committee to the MSC, and jointly funded by Doctors of BC and MSP, has no authority to audit but does have the mandate to provide advice to the MSC and educational information to physicians in regards to their patterns of practice and billing.

Where to get help: 

Canadian Medical Protective Association (CMPA) will review and assign a lawyer to you through this process. Please contact them directly at 1-800-267-6522.

Resources:

Visit the Doctors of BC website to find information and supports for billing and audits.

An audit tool designed for physicians is the Mini Practice Profile (MPP). Produced annually and available on the Doctors of BC website, the profile helps physicians to understand their pattern of billing. Mini Practice Profiles are provided to all fee-for-service physicians (after one year fee-for-service earnings of at least $1,000), based on the claims data submitted for payment to the MSP. 

Practice inspections

A practice inspection is conducted by the College of Physicians and Surgeons’ Physician Practice Enhancement Program (PPEP) who provides feedback to physicians about clinical practice, office management, and medical device reprocessing and sterilization. The program also provides recommendations for enhancement and improvement to support physicians and surgeons in their ongoing commitment to quality patient care. 

Physician assessments    

Physicians who have their own practice, work at a multi-physician or multi-disciplinary clinic, and/or perform long- and short-term locums can be randomly selected for this assessment. Physicians can also be selected through risk-prioritized selection if they work in a solo practice, or are 70 years or older.

Physician assessments are comprised of multi-source feedback (MSF), practitioner prescription profile (PPP), peer practice assessment (PPA), and physician interview. 

Where to get help:

• Sample multi-source Feedback (MSF) report
• Multi-source Feedback (MSF) reflection tool 
• Peer Practice Assessment (PPA) - Patient record selection instructions and guidelines 
• Peer Practice Assessment (PPA) - BC Assessment Framework and Scoring Rubric

Office assessments

Office assessments review and evaluate key areas of a community-based clinical practice as a whole, rather than the individual registrant who works there. A clinical office is identified through the assessment process of an individual registrant. A registrant is asked to provide information about their clinical practice and location of practice before they begin their physician assessment process.

Where to get help:

See the PPEP assessment standards for office assessments for more information. 

Physician Office Medical Device Reprocessing Assessments (POMDRA)    

Physician Office Medical Device Reprocessing Assessments (POMDRA) applies to all active registrants who practice in a community-based setting. This includes registrants in a solo or multi-registrant clinical office, as well as long-term and short-term locums. Community-based registrants who reprocess reusable semi-critical and/or critical medical devices in their clinical offices are identified through the College’s Annual License Renewal Form. Registrants may also be identified through the PPEP physician assessment process.

POMDRA does not apply to clinical offices or outpatient clinics which are under the direct jurisdiction of a health authority or hospital, and where Medical Device Reprocessing (MDR) practices are monitored and evaluated by the health authority.

Registrants selected for an assessment complete a pre-assessment questionnaire and if deficiencies are identified, recommendations for improvement will be provided in an MDR action plan. A final site assessment and report will be conducted by an assessor to ensure all deficiencies are resolved. 

Where to get help

• CPSBC – POMDRA best practices 
• POMDRA self-assessment tool

Canada Revenue Agency (CRA) audit

An audit initiated by the CRA is based on risk assessment factors such as the likelihood or frequency of tax return errors or whether there are indicators of non-compliance with tax obligations.

To assess these factors, the CRA examines taxpayers’ records to confirm whether a business is fulfilling its tax obligations, following tax laws correctly, and receiving their entitled benefits and refunds. Where to get help:

If your business is facing an audit of this kind, please connect with an accountant who can advise you throughout the process on what documentation will be required or questions needing to be answered. Business Pathways has professional services located within Club MD that will link to MNP LLP for this support (log in required). 

The experience of going through an audit is emotionally distressing and exhausting. The Physician Health Program is a free, confidential program which can provide peer support and counselling during this challenging experience. Phone the 24/7 intake line at 1-800-663-6729 to reach out for personalized support from our comprehensive team of physicians and case managers. Support can also be provided to those physicians who wish to remain anonymous.