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Policies that advocate for the medical profession and Canadians


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Auditing Physician Billings

https://policybase.cma.ca/en/permalink/policy1878
Last Reviewed
2019-03-03
Date
2004-12-04
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2004-12-04
Topics
Physician practice/ compensation/ forms
Text
Auditing Physician Billings Purpose: The CMA has developed a set of guiding principles to assist in the formation and modification of provincial/territorial billing audit processes. These principles will ensure that billing audit systems are fair, transparent, effective and timely, and that they uphold their original objectives of ensuring the accountability of public expenditures and educating physicians on appropriate billing practices. Background: As payments to physicians are made through public monies, the integrity of the payment system is validated through physician billing audits and reviews. Audits and reviews are usually prompted by: billings that appear to be outside of the “norm,” patient complaints, physician complaints or a “focus” on a particular service/area of practice/group of physicians. Each province/territory is responsible for and has in place particular processes and procedures to review physician billings. Billing audits can be stressful events that, regardless of the audit outcome, have had adverse effects on a physician’s health and practice. Although changes over the years in billing audit practices have occurred, they have not addressed all of the physicians’ concerns. Inadequacies in the existing procedures, such as the lack of a clear decision-making process, established review timelines and options for recourse still remain. In response to this situation, many provinces/territories are reviewing and modifying their existing billing audit process. The CMA and Canada’s physicians believe in an open, accountable and transparent health care financing system. It is for this reason that the CMA has developed this set of principles related to the key components of the audit process to ensure it is fair, efficient, effective and serves the purpose it was originally intended – to ensure the accountability of public funds and to educate physicians on proper billing practices. Principles: Education on proper billing practices: The audit and review process must be undertaken as an educational exercise. In a fee based system, billing code use and interpretation are complex and can often lead to unintentional errors. If or when inconsistencies occur, the physician must be alerted and provided with the opportunity to explain his/her billing behaviour. To assist in moving the audit and review process from under a cloud of perceived punishment to that of educational enlightenment, the repayment of any funds shall not commence until the audit and review process is complete and all appeal options have been exercised. As part of this overall educational framework, it is recommended that all newly licensed physicians be offered an educational program on proper billing interpretations, procedures and practices, and of the audit process itself. Fair, Transparent and Timely Process: In order for the audit and review process to be perceived as fair, it must operate at arms length from governments and the Colleges. As a profession, physicians have been granted the privilege of self-regulation by society. Given that medicine is a highly complex art and science, physicians are the only group truly qualified to set and maintain standards and to uphold accountability in matters of professional behaviour. The billing audit and review process must observe the principles of “Natural Justice” in that the: audit findings must be both impartial and be seen to be impartial and physicians affected by the findings must be offered a fair hearing by being given notice in writing of the findings; the opportunity to respond to the findings; all of the information to prepare a response; sufficient time to prepare a response; and an oral hearing if there is a dispute on factual matters or if requested by the physician. Physicians should be informed that legal counsel and assistance can be retained at any stage of the audit and review process. Physicians should consult with their respective provincial/territorial division or the Canadian Medical Protective Association (CMPA) to see whether such assistance is available, or with lawyers who specialize in this field. Specific time limits should be adhered to in the auditing and reviewing of a physician’s billings practice, particularly related to when the review period should commence and to the duration of the review period. For example, billings should not be reviewable more than 24 months after the service is rendered and the review period should not be greater than 12 months. These limitation periods recognize that physicians will not be able to recall, with certainty, the vast amount of information contained in a patient’s medical record over the past 10 years – the average length of time in which medical records must be held. It also ensures that audits and reviews are conducted in a timely fashion minimizing undue stress and hardship on the physician and, in light of the health human resources shortage, enabling them to re-focus their attention and energy on taking care of their patients. Informed Decision-Makers: Audits and reviews to determine whether there has been any incorrect or inaccurate billing should be undertaken solely by a physician’s peers, and where possible, consisting of physicians from the same specialty and subspecialty and with similar practice type, geography and demography. This peer review group shall consider age-gender distribution and the morbidity of the patients as well as other pertinent matters in arriving at its findings and conclusions. Outcomes: Any conclusions and/or findings from an audit and review must be prepared in a written report and forwarded, in a timely manner, to the physician and the paying agency. If either party is not satisfied with the findings, they have the option of launching an appeal. The preferred route would be to pursue and use Alternative Dispute Resolution processes since they tend to encourage a more co-operative climate resulting in fair and appropriate settlements, while avoiding the excessive financial, psychological and procedural costs that can be associated with formal court proceedings. Conclusion: These guiding principles are the product of an international, provincial and territorial scan of billing audit practices. They have undergone extensive consultation with the provincial/territorial medical associations and national medical organizations. They should be used to form the foundation of and to guide any reviews or modifications to existing provincial/territorial audit and review processes. CMA Policy, Medical Professionalism, 2002. Student Behaviour Guide_Natural.Justice.htm, Dec. 2002
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Third-party forms (Update 2017)

https://policybase.cma.ca/en/permalink/policy13643
Date
2017-05-27
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
Third-party Forms: The Physician's Role (Update 2010)
Short-Term Illness Certificate
Topics
Physician practice/ compensation/ forms
Text
A physician's assessment and signature on a third-party form have a value that reflects the physician's formal education and training as well as his/her professional experience. Similar to the signatures of other professionals, a physician's signature carries certain responsibilities and a commitment that the information provided is accurate and based on objective data and the patient's medical history. This value needs to be formally recognized and appropriately used. Most third parties have historically relied on the goodwill of physicians to complete their forms free of charge. However, the steady rise of third-party form requests (see Appendix A) and the cumulative time that form completion takes away from direct patient care necessitates a more reasonable approach to form requests and fair remuneration for the physicians' time and expertise. SCOPE OF POLICY This document provides guidance for physicians, patients and organizations that request third-party forms1 subject to federal/provincial/territorial legislation and regulations. Several strategies aimed at reducing the administrative burden of third-party forms are recommended to allow more time for direct patient care.2 GENERAL PRINCIPLES The physician's role * The physician has a well-defined and limited role in form completion - to only provide objective information on physical and/or psychological impairments and abilities, limitations and restrictions, time frames and prognosis from the medical record directly required by the third party for the purpose of administering particular programs or benefits. Questions on forms directed to physicians should be restricted to seeking such information. * A physician has a duty to ensure that he/she has properly completed the form (i.e., he/she has filled out the form completely, accurately and objectively in accordance with the requirements of the physician's provincial or territorial regulatory college). * When asked to provide an opinion on functional abilities to employers or insurers, the focus should be on abilities; information on restrictions should be objective and specific, and restrictions should be listed only when absolutely medically indicated.3 * A physician must not state that a patient has been under his/her care unless that is the case. The duration of the care should be indicated. If a physician does not have sufficient knowledge of an illness to provide information or an opinion upon it, the physician should state this on the certificate. The certification of absence should be based only on patient history if the patient was seen after the illness and should be clearly documented as "patient reports." In instances where a physician is being requested to complete a form by a transient patient (i.e., not the physician's patient), the physician should only comment on observations based on their own medical assessment. * A physician must have a patient's consent to disclose information to any third party, such as the patient's employer or insurer. Unless prevented by law, the physician should ensure the patient is aware that the report he/she provides to the third party is outside the physician-patient relationship and that in completing the form, the physician has a professional obligation to accurately and objectively report upon the patient's condition. A physician must not disclose more information than is covered by the patient's consent - this includes only providing information relevant to the nature of the request and that is reasonably necessary. If a patient limits his/her consent, the physician must consider whether such limitation is relevant to his/her report and if it is, report the limitation to the third party. * An accurate and relevant narrative summary of a patient's clinical files by the physician should be sufficient information for third parties. The requesting of complete copies of clinical files is unwarranted in the significant majority of cases unless mandated by legislation. * Physicians should consult with the Canadian Medical Protective Association and their provincial regulatory college for guidance and clarification on third-party form requests (see Appendix B). The patient's role * To the greatest extent possible, patients should review the third-party form and be aware of the information being requested. * Most forms request information on patients' subjective complaints and self-reported function. In such instances, it would be more appropriate to have this information reported directly by the patient to the requesting party. * Patients must be aware of the following: o Receipt of their consent authorizes the attending physician to accurately, completely and objectively explain the patient's medical condition as part of the physician's professional responsibility. o Physicians have a professional and ethical obligation to only document that which is true and medically defensible. The physician does not act as the decision-maker for absences or claims adjudication. o In some instances (e.g., fitness to drive), physicians also have legislated requirements to complete third-party forms regarding their patient. The role of the third party * Third parties should only request medical forms when there is a need for medical information about a patient (i.e., information that could not be provided by a non-physician) to be used for employment/education purposes or the evaluation of a medically related benefit for the patient. o It is the role of the third party to adjudicate on a patient's eligibility for a benefit, not the physician. o A request for a patient's non-medical information (i.e., unrelated to the patient's medical condition/history) or a request to certify identity (e.g., asking a physician to certify the principal parent for the purpose of determining eligibility to receive child benefits) is an inappropriate use of medical resources and it is at the discretion of the physician whether to comply with such requests. o Requests for updates should be reasonable and respect the physician's prognosis. o Wherever possible, third-party forms should be standardized (e.g., program eligibility, tombstone data, wording of questions) to save time and reduce administrative errors. o Program eligibility should be made clear to patients and providers to reduce inappropriate form requests (e.g., educating tax advisors on government program eligibility to prevent inappropriate requests for the disability tax credit). * To make the process of completing a medical form effective and efficient, third parties must involve and inform physicians early and on an ongoing basis, beginning by asking physicians to help to determine whether there is a need for a medical form to be completed in the first place. Medical input is also necessary in the design of the form and to determine how often the form needs to be completed. Physicians should be involved in periodic reviews of existing medical forms with third parties (e.g., governments, insurance companies, associations) for several reasons: to determine whether the forms remain relevant and as a simple as possible; to determine appropriate remuneration for completing the forms; and to ensure that physicians are notified of any changes to requests for medical certification in writing rather than having changes communicated to the physician informally through the patient.4 * In some cases, other health professionals (e.g., occupational therapists) are in a better position to objectively assess patients' abilities and could be designated as qualified practitioners for the purpose of completing the forms, with physicians providing information pertaining to medical assessments and prognoses. Short-term illnesses * Confirmation of a short-term absence from work because of minor illness is a matter to be addressed between an employer and an employee directly. Such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources. It is the employer's responsibility -not the physician's - to oversee employee absenteeism. It may be that for many cases, the need for a medical certificate can be replaced by a more effective alternative that does not involve physicians and is agreed to by all parties concerned (e.g., employer and employees). * If an employer, educational institution or other third party requests an illness confirmation certificate for a short-term, minor illness that would otherwise not have required medical attention, said party should recognize that completion of the certificate is an uninsured service for which physicians are entitled to compensation, preferably from the third party requesting the information, rather than burdening the patient. Fair compensation * The third party requesting the information should be responsible for compensating the physician for their medical information and expertise. At a provincial/territorial government level, this could mean making the completion of provincial/territorial forms an insured service under the provincial/territorial health insurance plan. * Physician reimbursement should cover the time and resources devoted to the provision of medical information to third parties (submitted in writing, electronically and/or by phone). This includes compensation for any uninsured medical assessment necessary to complete the form, for the provision of copies of medical information, and for the time and resources needed to respond to any follow-up requests. Wherever possible, the compensation rates should be consistent and should reflect the time and effort necessary to complete the form(s). * Physicians should be compensated for completing forms related to return to work by provincial/territorial worker's compensation plans; they should be compensated for completing return-to-work forms for non-occupational conditions by provincial/territorial insurance plans, given the important health implications of return-to-work management. * In the absence of third-party compensation, physicians may charge the patient for the service they provide. As stated in the CMA's Code of Ethics, physicians should consider the nature of the service provided and the ability of the patient to pay, and they should be prepared to discuss the fee with the patient.5 Patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship or pose a barrier to accessing health care services. The physician may decide to reduce or waive his/her fees if the patient lacks the financial ability to pay. Physicians should consult their provincial/territorial medical association for guidance regarding direct billing of patients. Appendix A The increasing administrative burden Physicians face a multitude of requests on a daily basis to complete medical forms and certificates. Requests come from many sources, including governments, government agencies (e.g., workers' compensation boards) and the private/non-governmental sectors (e.g., employers, insurance companies, schools, sporting organizations). In a 2016 survey of CMA physician members on third-party forms, physicians identified sick notes as the form that they were most frequently asked to complete (67.0% of respondents reported having to fill this form out more than five times per week). Short-term disability claim forms were the second most frequently requested form, with 42.3% of respondents reporting completing this form more than five times per week. Medical certificates for sickness benefit claims under the federal government's employment insurance program - just one example of a third-party form requiring medical input - had to be completed for 336,800 approved applications in 2013-20146 (the vast majority of these certificates would have been completed by physicians). Physicians continue to devote considerable time to completing forms. Government disability forms, just one type of third-party form, require considerable amount of time to complete. Over 62% of the physicians in the 2016 survey indicated they spend 21-30 minutes (31% of respondents) or more than 30 minutes (31% of respondents) to complete the Canada Pension Plan disability form. Similarly, 60% indicated they spend 21-30 minutes (33% of respondents) or more than 30 minutes (27% of respondents) to complete the Veterans' Affairs disability benefit form. The most frequently identified concern that physicians have with completing third-party forms (75% of those who participated in the 2016 survey) was the time it took from direct patient care. The second most frequently identified concern (63.4%) was the number of inappropriate requests from third parties.7 Increasing administrative workload/paperwork has been identified by physicians as one of the biggest contributors increasing the demand for their time at work. 8 In many cases, these requests can be an inappropriate use of a physician's time, such as requests for patient information for administrative purposes. Responding to such requests reduces both timely access to care and the time available for direct patient care. Appendix B Policies in the office to better manage third-party form requests Office policies and strategies can be instituted by physicians to better manage third-party requests. These strategies include: * having an office policy or standardized method to manage third-party form requests; * having clear communication and posted signage on patient and physician responsibilities regarding forms and fees; * using a standard form template (e.g., for sick notes)9; and * organizing time to complete forms. Physicians are also encouraged to consult with their provincial/territorial medical association and their regulatory college for guidance related to form requests. These strategies can be part of an overall effort by organizations to raise the awareness of employers, governments and other third parties of the need for a more appropriate approach to form requests to eliminate time wasted for all parties and reduce the inappropriate use of health care resources. 1 The term third-party form refers to any form, letter, medical certificate, mandatory reporting form, photocopy or other document containing medical information about the patient that a physician has been requested to complete or provide by a third party on behalf of their patient. [0]The term third party refers to an employer, government department or agency, private insurer or other organization that is requesting medical information about the patient with the intention of using it. 2 This policy should be considered in conjunction with CMA's policy statement entitled The Treating Physician's Role in Helping Patients Return to Work after an Illness or Injury. 3 Choosing Wisely Canada. Occupational Medicine Specialists of Canada. Five things physicians and patients should question; 2014 Oct 29. Available: www.choosingwiselycanada.org/wp-content/uploads/2014/09/Occupational-Medicine.pdf 4 Saskatchewan Medical Association. SMA relative value guide. Saskatoon: The Association; 2004. 5 Canadian Medical Association. Code of Ethics. Ottawa: The Association; 2004. 6 This figure does not include the number of forms completed for individuals who applied but did not qualify for the program. Canada Employment Insurance Commission. Employment insurance monitoring and assessment report 2013/14. Ottawa: Employment and Social Development Canada. Available: www.esdc.gc.ca/en/reports/ei/monitoring2014/chapter2_4.page 7 Canadian Medical Association. e-Panel survey summary: third-party forms. Ottawa: The Association; 2017. 8 Royal College of Physicians and Surgeons of Canada. National physician survey 2013. Results by FP/GP or other specialist, sex, age and all physicians [table]. Ottawa: The College; 2013. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/08/2013-National-EN-Q13r.pdf 9 Steven Harrison. OMA sickness certificate template: a practical office resource. Ontario Medical Review 2004 Dec.
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