Any physician who has had their billings audited finds the experience stressful. Unfamiliarity with the audit process only increases that stress level. 

Effective December 1, 2020, the responsibility for physician remuneration audits was transferred from Manitoba Health to the Department of Finance. Any notifications respecting audits will now come from the Comptrollership and Compliance Unit (CCU) within the Office of the Provincial Comptroller. 

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

Even though Doctors Manitoba is here 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.

The CCU, within the Department of Finance, is now responsible to ensure 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” (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 transferred these duties to the CCU, which fulfills the functions noted above.

Audits by the CCU may be triggered in several ways, including:

• A physician’s billing pattern may appear to the CCU to be ​“out of the norm”;
• A patient may lodge an inquiry/​complaint with Manitoba Health or the CCU;
• Another physician may make an inquiry/​complaint with Manitoba Health or the CCU;
• The CCU may decide to ​“focus” on a particular service, area of practice or group of physicians;
• Manitoba Health may request that the CCU audit a physician;
• The College of Physicians & Surgeons of Manitoba may refer a matter to Manitoba Health.

CCU audits generally commence with a letter being sent to the physician advising that there is some concern/​interest in a particular aspect of the physician’s billing. The physician is asked to provide the auditor with access to copies of selected patient charts, and sometimes also with copies of day sheets, appointment books, etc. There is generally a 30 day time limit to respond.

Most audits by the CCU have involved patient records from two to four years ago. However, there is no restriction on the time period of an audit.

Once the auditor has reviewed the documentation provided by the physician, they will contact the physician and provide the CCU’s position. The auditor may determine that, in their opinion, a certain number of claims were incorrectly made and that a repayment to Manitoba Health is being sought.

A physician has 90 days from the date of the letter from the CCU to appeal the findings of an audit. Any enforcement of the alleged overpayment by Manitoba Health will be suspended while the appeal is pending. The appeal will be heard by a panel chaired by an independent person agreed upon by representatives of Doctors Manitoba and Manitoba Health, usually a lawyer.

If a physician does not appeal, Manitoba Health will recover the amount, in most cases by withholding future billings until the amount is repaid.

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: the CCU may audit the same physician within a reasonable time frame to determine if there has, in fact, been a change in billing practice.)

Questions?

Andrew Swan
aswan@​doctorsmanitoba.​ca
(204) 985‑5860