Billing for benefits and nonbenefits on the same visit

The Billing Integrity Program is seeing a mixing of services—benefits with nonbenefits—appear on audits. Preamble C.1 in the Doctors of BC Guide to Fees states:

“Benefits” under the Act are limited to services which are medically required for the diagnosis and/or treatment of a patient, which are not excluded by legislation or regulation, and which are rendered personally by medical practitioners or by others delegated to perform them in accordance with the Commission’s policies on delegated services.

Services requested or required by a “third party” for other than medical requirements are not insured under MSP. Services such as consultations, laboratory investigations, anesthesiology, surgical assistance, etc., rendered solely in association with other services which are not benefits also are not considered benefits under MSP, except in special circumstances as approved by the Medical Services Commission (e.g., Dental Anaesthesia Policy).

For example, the following scenarios would not be considered benefits:

•    Billing a patient for a cosmetic procedure (not a benefit), but then billing MSP the follow-up visit as an office visit.
•    Ordering laboratory tests in connection with nonbenefits such as periodic company medical examinations or periodic medical examinations in the office where there is no medical issue.
•    Billing MSP for third-party requirements (e.g., billing MSP for a complete examination when the service is a pre-employment examination for a company or organization).

If benefits and nonbenefit services are provided on the same visit, the medical record must clearly reflect a separation. If you are doing a lot of nonbenefit work, it is advisable to keep those visits completely separate and on different days from visits relating to benefits work.
—Keith J. White, MD
Chair, Patterns of Practice Committee

References

This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, audit and billing advisor, Physician and External Affairs, at 604 638-2829 or jgrant@doctorsofbc.ca.