Billing Issues Identified through Independent Health Facilities Program

September 25, 2015

Independent Health Facilities ProgramHealth Services Branch

Negotiations and Accountability Management Division

MOHLTC Presentation to Independent Diagnostic Clinics Association

Presentation to IDCA – IHF Program

• Introduction

• Focus – Billing Issues Identified via IHF Program Functions

• Purpose – Appropriate use of Public Funds, Value for Money, Best Patient Care

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Agenda

• Sources/Triggers of Reviews and Outcomes

• Recent General Communication Initiatives

• Possible Future General Communication Initiatives

• Individual Communication

• Examples of Billing Issues

• Resources and Point of Contact

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Sources/Triggers of Reviews and Potential Outcomes

Sources/Triggers:• Complaints• Billing Analysis • Referrals from other Ministry Areas• Ministry review of Quality Assessment reports

Outcomes:• Resolve• General Communication - Letter to all licensees,

Bulletin• Individual communication to specific licensees • Repayment - voluntary• Referral to Payment Accountability who review IHF

facility fees

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General Communication Initiatives 2014/2015:

• Bulletin regarding requisitions

• Communication by letter regarding proper billing for General Ultrasound Services

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Possible Future General Communication Initiatives:

• Myocardial Perfusion Scintigraphy (J807/J808 for 2-day protocols)

• Schedule requirements for billing J149• Vascular Ultrasound (eg. unilateral study for possible

DVT in one limb) • General Radiology (eg. number of views for x-rays)• Follow-Up of ultrasound concerns discussed in General

Communication Letter sent July 2014• Sleep Medicine – new Clinical Practice Parameters and

Facility Standards and if appropriate billing practices

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Individual Communication

• May be included in letter from the Director post Quality Assessment

• May involve a separate letter• Issues raised are reviewed by the IHF Program

including claims analysis first• Typically there is a future analysis to determine

modification of claims patterns• May result in referral to Payment Accountability at the

time when concern is identified or if there is no change in billing pattern when claims reviewed subsequent to the communication

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Examples of Specific Issues that have been Identified:

• Multiple service dates for one service (eg. US extremity, vascular US (peripheral arterial/venous))

• Billing for Services not rendered (eg. US head and neck when rendering Vascular Scan of Carotid arteries)

• Routine addition of tests not ordered by requesting physician (eg. US with mammograms, US abdomen/pelvis/transvaginal, vascular US (limited abdomen and pelvis))

• Requisitions – extra tests due to wording (“Well Woman’s Exam”, X-rays being done with any US ordered, inability to order unilateral examinations (eg. US of extremity with breast or peripheral arterial/venous US))

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Examples of Specific Issues that have been Identified:

• Medically Unnecessary Tests (eg. routine follow-up testing, extra views of x-rays for patients, therapeutic sleep studies prior to seeing patient)

• Up-coding (eg. complete pelvic US when follicle monitoring rendered, billing for comparison views, myocardial perfusion scintigraphy (J807 times 2 for 2-day protocol versus J807/J808 for 1 and 2-day protocols))

• Unbundling (eg. adding US extremity for scanning Axilla when rendering breast US)

• Submission of claims using a physician’s billing number who is not the interpreting physician

• Billing for interpretations when physician is not in Ontario

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Resources and Contact

• Independent Health Facilities Act

• Schedule of Facility Fees

• IHF Website: http://www.health.gov.on.ca/en/public/programs/ihf/

• IHF Program: IHFP@ontario.ca

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