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Learn about health professional compliance reviews, billing errors and abuse, and how to make complaints about health care fraud.
The Alberta Health Care Insurance Act and its regulations form the governing legislation of the Alberta Health Care Insurance Plan (AHCIP). The act and the AHCIP establish the payment rules for physicians and other practitioners when providing insured health services to Albertans.
Other practitioners include chiropractors, denturists, dentists, opticians, optometrists or other people who provide basic health services or an extended health service.
To assure accountability and the protection of taxpayers’ dollars, claims submitted to the Alberta government for payment are monitored. Data analysis, risk assessment methodologies, public tips and complaints are used to identify potential billing errors or issues. One, or a combination, of these activities may trigger a compliance review, which could identify non-compliance with legislation and lead to the recovery of overpayments.
A compliance review assesses or reassesses submitted claims for compliance, facilitates recovery of incorrectly paid funds, and promotes compliance with the Alberta Health Care Insurance Act, the AHCIP, the Schedule of Benefits such as the Schedule of Medical Benefits, and pertinent legislation.
A compliance review is an administratively fair process in which the Alberta government notifies a physician or other practitioner of the review and requests pertinent documents. After the review is complete we share interim findings. Practitioners are then provided an opportunity to respond to these findings prior to the review’s conclusion.
The Alberta government may initiate a compliance review based on concerns resulting from any one or more of the following:
If necessary, we may visit the physician’s or practitioner’s office (announced or unannounced), to obtain additional documentation and electronic records. We may conduct interviews of physicians or other practitioners and their staff during these onsite visits.
A compliance review involves:
Physicians and other practitioners are required to have sufficient and appropriate documentation to support the health care services they have identified as being provided in their submitted claims. The documentation a physician must be able to provide when requested must be consistent with the Patient Record Standards of Practice as established by the College of Physicians & Surgeons of Alberta (CPSA). Other practitioners must have documentation to meet the standards established by their college.
Where a Notice of Reassessment has been issued at the conclusion of a compliance review, the physician or other affected practitioners can seek to have that reassessment varied or vacated by the Minister’s Delegate or may file an appeal to Alberta Court of Queen’s Bench within the statutory timelines established by the Alberta Health Care Insurance Act.
Administrative fairness is about natural justice, due process, and procedural fairness. During a compliance review, the Alberta government adheres to the following administrative fairness objectives:
Incoming tips and complaints can trigger the compliance review of a particular practitioner. This process is confidential in order to safeguard the privacy of both the source of the complaint and the subject of the complaint.
To report complaints of suspected billing abuse, contact the Compliance and Monitoring Branch.
Provide as much information as possible to help government officials assess and respond to your tips and complaints.
Where information provided or otherwise obtained indicates a practitioner’s activities in the provision, receipt, or payment of publicly funded health services may constitute an offence under either provincial legislation or the Criminal Code, the file may be referred to Service Alberta’s Health Investigations Unit (HIU).
HIU has the authority to investigate criminal matters, including fraudulent physician claims made to the AHCIP. The HIU can be contacted at [email protected] if you believe a potential criminal matter requires further attention.
A physician may choose to report another physician’s conduct to the CPSA if that physician becomes aware that another physician’s conduct may constitute an ethical violation of the bylaws, standards of practice, or Code of Ethics of the CPSA.
The CPSA addresses issues related to physician standards of practice and quality of care and has a clearly defined process to address complaints.
Other colleges also address issues related to standards of practice for their members.
If physicians or other practitioners have submitted a claim but subsequently become aware of errors or that it was not in non-compliance with the Alberta Health Care Insurance Act, they can resubmit the claim within 90 days of providing the insured service.
If the error or non-compliance is discovered by the physician or practitioner 90 days after they provided the insured service, a practitioner can still report the discrepancy to us with adequate supporting evidence and where appropriate include repayment of any identified overpayment.
The Alberta government will not charge interest or penalties to physicians or other practitioners who choose to repay the overpayment resulting from the voluntary disclosure of erroneous claims, when:
The Alberta government applies the practitioner’s relevant health profession’s Standard of Practice as the minimum level of evidence they must provide when a claim for benefits is subject to review.
A written request is provided to the practitioner outlining the response period for submitting records. The response period is usually 30 calendar days from the date of the written request. Extensions may be granted in extenuating circumstances.
If a physician or other practitioner does not negotiate an accepted extension to submit records or provide required records to support their claims for benefits in time, we may:
Where the Alberta government has initiated a compliance review of a physician’s or practitioner’s claims, the Alberta Health Care Insurance Act allows us the ability to withhold or reduce all, or a portion of, benefits payable under the AHCIP to that physician or practitioner.
We may withhold or reduce a physician’s or other practitioner’s benefits in the following circumstances:
All submitted claims for benefits are subject to assessment and approval by the Alberta government prior to payment.
When a physician or other practitioner submits a claim for benefits, we may request further information about the claim prior to payment. We may start an enhanced claims assessment requiring additional information to support the assessment and payment of claims.
The Alberta government’s compliance review may identify non-compliant claims from those submitted by physicians and other practitioners.
Findings may include, but are not limited to, instances where the physician or other practitioner:
In such circumstances we may request additional information from the physician or other practitioner, reassess the claims submitted to different HSCs or modifiers or reassess the claims submitted to $0.00, or all 3, as appropriate.
Where a Notice of Reassessment identifies an overpayment owing by the physician or practitioner to the Alberta government, the person being reassessed will be provided repayment terms regarding the overpayment amount.
The repayment terms will include the following:
The amount owing to the Alberta government as a result of the compliance review includes:
The repayment period is the time identified for a physician or other practitioner to pay the repayment amount. The allowable time period will be specified in a repayment agreement with the Alberta government.
A physician or other practitioner may challenge a Notice of Reassessment issued by the Alberta government with a request for a Minister’s Delegate review. If a review is requested, a Final Notice of Reassessment will be issued by the Minister’s Delegate.
A Minister’s Delegate review involves an impartial and independent review of our claims reassessment, the practitioner’s correspondence and pertinent documents provided to government.
A physician or other practitioner may make an appeal to the Court of Queen’s Bench either:
The Compliance and Monitoring Branch conducts monitoring activities and compliance reviews of physicians or other practitioners’ claims for benefits and pursues recovery in accordance with the Alberta Health Care Insurance Act.
In the course of its activities, the Compliance and Monitoring Branch may determine that certain conduct, as it relates to the submission and payment of claims, may constitute a fraudulent offence on the AHCIP.
These fraudulent offences may be perpetrated by both Alberta residents as well as physicians or practitioners.
We recognize the vast majority of health care service providers and Alberta residents are honest and ethical. However, there are a small number of individuals who attempt to deceive the Alberta government. This could be physicians or other practitioners who deliberately seek payment for services not rendered, or residents who obtain publicly funded medications, or health services, which they are not legally entitled to receive.
Fraud is an act of deception or misrepresentation by individual(s), to obtain benefits, for which they normally are not eligible. Fraud is an offence defined in Section 380 of the Criminal Code of Canada and anyone found guilty of fraud may face up to 14 years imprisonment. In addition, identifying potential fraudulent conduct may serve as a trigger to conduct a compliance review, which may result in the Alberta government recovering the wrongfully paid amounts, and reporting the conduct to the relevant professional college or association.
Some common examples of fraudulent behaviour in the health-care system are:
To promote a sustainable health-care system, it is recommended physicians and practitioners implement the following measures to prevent fraud on the public health-care system:
Physicians and practitioners are encouraged to report any inappropriate billing or suspected health care fraud.
Incoming tips and complaints could trigger a practitioner compliance review or audit. This process is confidential, to safeguard the privacy of both the complainant and the subject of the complaint.
To report complaints of suspected billing abuse, contact the Compliance and Monitoring Branch
If you suspect that an individual is misusing or not using their own Alberta Health Care Insurance card, contact the AHCIP tips line at 1-866-278-5104 or by email at [email protected].
If you believe these incidents involve ethical violations by physicians, you may also send a complaint to CPSA. The college addresses issues related to physician standards of practice and quality of care and has a clearly defined process to address complaints. Other practitioners can be contacted through their respective colleges.
Bulletins for Health Professionals
Alberta Health Care Insurance Act
Claims for Benefits Regulation
Alberta Health Care Insurance Regulation
The Canadian Health Care Anti-Fraud Association
The National Health Care Anti-Fraud Association
Connect with the Compliance and Monitoring Branch:
Email: [email protected]
Mail:
Alberta Health
Compliance and Monitoring Branch
PO Box 3160 Stn. Main
Edmonton AB T5J 2N3
Register a complaint with the College of Physicians and Surgeons of Alberta:
Phone: 1-800-661-4689
Email: [email protected]
Contact information for a college responsible for a provider’s profession
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