Audits by Manitoba Health

Any physician who has been the subject of an audit by Manitoba Health can attest to the fact that the experience can be anxiety inducing to say the least. Unfamiliarity with the audit process only increases that stress level.

The first step any physician should take when receiving a notice of audit from Manitoba Health is to call Doctors Manitoba for specific advice.  This should be done even before responding to or speaking with an auditor.

Despite the fact that Doctors Manitoba is there to help you, all fee-for-service physicians, whether the subject of an audit or not, should have at least a rudimentary understanding of the audit process.

The following is a brief and general outline of the process.

  • As the government agency responsible for payment for insured medical services, Manitoba Health is also charged with the responsibility of ensuring that claims for insured medical services comply with the provisions of the Physician’s Manual.
  • To that end, under The Health Services Insurance Act:
    1. the Minister of Health may appoint inspectors (aka auditors), and
    2. inspectors have the right to enter a physician’s office and examine/make copies of any books, accounts, records, patient charts etc. relating to claims for benefits for insured services.
  • Manitoba Health has an Audit and Investigations Department which fulfills the functions noted above.
  • Audits by Manitoba Health may be triggered in a number of ways, including:
  • Manitoba Health has an Audit and Investigations Department which fulfills the functions noted above.
  • Audits by Manitoba Health Health may be triggered in a number of ways, including:
    • a physician’s billing pattern may appear to Manitoba Health to be “out of the norm”;
    • a patient may lodge an inquiry/complaint with Manitoba Health;
    • another physician may lodge an inquiry/complaint with Manitoba Health;
    • Manitoba Health may decide to “focus” on a particular service, area of practice or group of physicians;
    • a physician may be identified through Manitoba Health’s Random Physician Audit Process;
    • the College of Physicians & Surgeons of Manitoba may refer a matter to Manitoba Health;
    • the Medical Review Committee (MRC) may have reviewed a physician’s pattern of practice and referred the matter to Manitoba Health for further investigation.
  • Manitoba Health audits generally commence with a letter being sent to the physician from a Manitoba Health auditor, and being advised that there is some concern/interest in a particular aspect of the physician’s billing. The physician is asked to provide the auditor with copies of selected patient charts, and sometimes also with copies of day sheets, appointment books, etc.
  • Once the auditor has reviewed the documentation provided by the physician, they will thereafter contact the physician and provide Manitoba Health’s position. In general, the position may include a statement that the physician’s charts are acceptable and the audit is complete. In other cases they auditor may have determined that, in his/her opinion, a certain number of claims were incorrectly made and that a repayment to Manitoba Health is being sought.
  • Where Doctors Manitoba has been asked to represent a physician, it will do its own review. Where a repayment has been requested, Doctors Manitoba may obtain one or more independent opinions from other physicians with expertise in the field regarding the billing matter(s) in issue. Doctors Manitoba will then begin a process of negotiation with the auditor, with a view to eliminating or reducing the amount of repayment that will be required of the physician.
  • When an agreement is arrived at with respect a repayment, if any, the matter is then concluded. (Note: Manitoba Health may audit the same physician within a reasonable time frame to determine if there has, in fact, been a change in billing practice.)
Questions

Allison Crolly
acrolly@doctorsmanitoba.ca
(204) 985-5856