Health professionals – Audit and compliance assurance

Overview

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.

Connect with a regulated health profession college

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.

Compliance review

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.

Determining which physician or practitioner to review

Factors that may inform the Alberta government initiating a compliance review include, but are not limited to:

complaints or tips, either from a member of the public or a colleague
data analytics and trend analysis
other analytic and monitoring activities, including risk assessments
news, or media releases from governing bodies
information from other compliance reviews

Onsite visits

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.

Compliance review process

A compliance review involves:

reviewing claims data to identify potential errors or issues
reviewing patient charts, to verify errors or issues
communicating with physicians and other practitioners to inform them about the findings of claim errors or issues via a Notice of Findings, and requesting explanations and further documentation such as patient records, work schedules, and rationale for billing practices
evaluating the physician’s or practitioner’s response
concluding and explaining findings and an overpayment amount identified via a Notice of Reassessment
providing repayment and appeal options

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 is required 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 or minimum expectations established by their college or as required by Alberta Health.

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 King’s Bench within the statutory timelines established by the Alberta Health Care Insurance Act.

Administrative fairness

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:

giving physicians and other practitioners a full and fair opportunity to present their billing information and rationale
providing full disclosure and all necessary information to the physicians and other practitioners during the course of a compliance review
consulting with physicians and other practitioners who are the subject of the compliance review and seeking their feedback on the compliance review’s findings
reviewing the findings after receiving physicians’ and other practitioners’ feedback, and providing them with our decision
informing physicians and other practitioners about the options for repayment and any options to appeal the decision
engaging physicians and other practitioners and treating them professionally throughout the compliance review and decision-making process

Suspected billing abuse

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 Audit and Compliance Assurance Unit.

Provide as much information as possible to help government officials assess and respond to your tips and complaints.

Suspected criminal activity

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.

Ethical abuse

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.

Learn more about this process

Other colleges also address issues related to standards of practice for their members.

Connect with a regulated health profession college

Process details

Voluntary self-disclosure

If physicians or other practitioners have submitted a claim but subsequently become aware of errors or that it was not in compliance with the Alberta Health Care Insurance Act, they can make appropriate adjustments to the claim within 90 days of providing the insured service. This includes changing the existing claim or deleting an incorrect claim and submitting a new claim with the correct information.

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:

payments are made within 30 calendar days of informing us of the voluntary self-disclosed overpayment
disclosure is made in good-faith without attempting to frustrate, delay or otherwise circumvent a pending or ongoing inquiry, practitioner compliance review, criminal proceeding or investigation, either before or after the self-disclosure
the billing conduct in question has ended prior to the disclosure and the physician or other practitioner has taken the necessary corrective actions to avoid future re-occurrence

Evidence and timelines

Evidence

Alberta Health uses descriptions and requirements published in Bulletins for health professionals, listed the Schedule of Medical Benefits, and Medical Governing Rules List to assess evidence supporting claims submitted.

In addition to specific or additional directives from Alberta Health, 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.

Timelines

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:

consider those health services as inadequately documented
deem those health services to have not been provided
assess or reassess the claimed health services as non-compliant and not payable

Withhold or reduce future benefits

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:

Denial of access to records or failure to respond to inquiries – Payment of any or all benefits may be withheld until the practitioner has satisfactorily answered questions or until the practitioner has provided the required access to patient records.
Non-compliance with applicable legislation – Where it has been determined the physician or other practitioner has not complied with applicable legislation, we may:
- withhold payment of some or all benefits until the situation is resolved

Enhanced claims assessment

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.

Practitioner compliance review findings

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:

has patient records that do not support the provision of the Health Service Codes (HSCs) in the submitted claim(s) or any other HSCs in the Schedule of Medical Benefits (SOMB)
has submitted claims for uninsured services or services not listed as benefits in the SOMB
has failed or neglected to provide patient records, or
has provided patient records that lack the evidence to support the provision of service rendered on the date of service claimed

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.

Repayment terms

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:

Repayment amount

The amount owing to the Alberta government as a result of the compliance review includes:

the total reassessed amount as identified in the Notice of Reassessment
simple interest of 8% per annum, effective 30 days after the date on the Notice of Reassessment, calculated on the reassessed amount outstanding at the end of each month during the repayment period

Repayment period

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.

Repayment options

There are flexible repayment options. A physician or other practitioner may choose from available repayment options and enter into an agreement with the Alberta government concerning repayment terms.
The terms stipulate the conditions specific to each option, which may include repayment by certified cheque or repayment by withholding. When a physician or other practitioner elects to pay by certified cheque, they will either pay by lump sum or by instalments with applicable interest.
Payment by withholding involves offsetting the repayment amount with the physician’s or other practitioner’s future submission of claims.

Appeal mechanisms

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.

The practitioner must apply for a Minister’s Delegate review in writing within 30 calendar days of the date on the Notice of Reassessment.

A physician or other practitioner may make an appeal to the Court of King’s Bench either:

after receiving a Notice of Reassessment, without requesting a Minister’s Delegate review, or
after challenging the Notice of Reassessment to the Minister’s Delegate, and receiving the Minister’s Delegate Final Notice of Reassessment

Reporting health care fraud

The Audit and Compliance Assurance Unit 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 Audit and Compliance Assurance Unit 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 and 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.

Example of fraud

Some common examples of fraudulent behaviour in the health-care system are:

Health practitioners

submitting claims for services not provided
up-coding – submitting claims for more expensive services, procedures or products than were actually provided
un-bundling – separately billing for each component of a procedure, as opposed to billing a single health service code that covers the entire procedure
uninsured services – submitting claims for uninsured services by presenting them as medically necessary

Patients

double-doctoring – obtaining prescriptions from multiple medical practitioners through deceit
prescription-altering/theft – fabricating or stealing prescriptions to obtain un-prescribed medications (typically narcotics)

Other persons

identity deceit – wrongly using another individual’s identity to obtain publicly funded medications or health services
non-residents – obtaining AHCIP coverage through misrepresentation about their status as a resident of Alberta or Canada

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:

ensure all medically necessary and insurable services are supported with appropriate documentation in patient records
protect prescription pads and blank medical forms, for example, save the forms in a secure non-public storage area
submit accurate fee-for-service claims to reflect the services provided
clarify claim submission concerns with our billing specialists, and
request secondary identification, (for example, government issued picture identification, billing statement or utility bill with a current address) if concerned about the identity of the person requesting Alberta Health Care Insurance coverage

Complaints

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.

Suspected billing abuse

To report complaints of suspected billing abuse, contact the Audit and Compliance Assurance Unit

Misuse of AHCIP card or suspected billing abuse

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].

Ethical violations

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.