SASKATCHEWAN MEDICAL ASSOCIATION by Levone

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									SASKATCHEWAN MEDICAL
     ASSOCIATION



  INTRODUCTION TO BILLING



      FOR PHYSICIANS



     IN SASKATCHEWAN



        September 2000
                                                                                INDEX


Appeal procedures .....................................................8                     Temporary Health Coverage (THC) ....................2
Assessment rules                                                                             Workers’ Compensation Board (WCB) ...............2
      Concurrent procedures .......................................7                    Help for physicians
      "0" and "10" day rules .........................................7                      Correct Claims Corner CCC) ............................10
      Out-of-Hours premiums ......................................7                          Member Advisory Committee............................10
      Surcharges - where they apply ..........................7                         Joint Medical Professional Review Committee ..........8
      Visits and procedures .........................................7                  Lawyers - reports to ...................................................9
Billable uninsured services.........................................9                   Locum Tenens ...........................................................4
Billing                                                                                 Medical Services Plan of Sask Health MSP ...............2
      Process                                                                           Member Advisory Committee (MAC)........................10
      Composite fee ....................................................7               Minimizing billing errors..............................................6
      Diagnosis on claims ............................................6                 Modes of billing ..........................................................4
      Explanatory Code for Physicians ........................7                         New procedures .........................................................5
      Insufficient postage on claims .............................4                     No show, no dough ....................................................3
      Locum tenens .....................................................4               "0" and "10" Day Rules...............................................7
      Minimizing billing errors ......................................6                 Office
      Modes of billing ...................................................4                  accounting systems ............................................1
      New procedures..................................................5                      establishment of..................................................1
      Payment Schedule..............................................5                   Out-of-hours premiums ..............................................7
      Registration for billing .........................................4               Out-of-province referrals. ...........................................3
      Reports to MSP                                                                    Paying agencies - insured services............................2
            -billing in error ..............................................7                               - other provinces/territories .............2
            - confidentiality.............................................6             Payment Schedule .....................................................5
      Service codes and fees.......................................5                    Premiums - for out-of-hours. ......................................7
      Submission of claims ..........................................6                  Referrals
      Time limit on accounts ........................................5                       to consultants .....................................................4
      Verification of accounts to MSP ..........................8                       Registration for billing.................................................4
General considerations about billing                                                    Relative Value Guide .................................................8
      Billing more than one agency..............................3                       Reports to:
      Guiding principles ...............................................3                    lawyers................................................................9
      No Show, No Dough ...........................................3                         MSP - confidentiality ...........................................6
      Referrals to specialists ........................................3                           - billing in error ...........................................7
      Referring out of province.....................................3                        other third parties ................................................9
      Services to own family ........................................3                  Royal Canadian Mounted Police (RCMP) ..................3
      Supervised services............................................3                  Saskatchewan Cancer Foundation (SCF)..................2
Canadian Armed Forces personnel............................3                            Saskatchewan Government Insurance (SGI).............2
Claims submissions ...................................................6                 Saskatchewan Health (Medical Services) ..................2
Composite fee............................................................7              Service codes and fees - selecting............................ 5
Concurrent procedures ..............................................7                   Services to own family .............................................. 3
Consultants                                                                             School student injuries ...............................................9
      Family Physician .................................................4               Specialist rates ..........................................................3
      Referrals to .........................................................4           Students injured at school..........................................9
Correct Claims Corner (CCC) ..................................10                        Submission of claims to insuring agencies.................6
Department of Veterans' Affairs (DVA) ......................3                           Supervised services ..................................................3
Diagnosis on claims ...................................................6                Surcharges - where they apply...................................7
Explanatory Code For Physicians ..............................7                         Time limit on accounts ...............................................5
Fees -see service codes and fees..............................5                         Telephone advice - uninsured ...................................9
Family Physician - consultants...................................4                      Uninsured services
Insured services paying agencies                                                             Billable uninsured services..................................9
      Canadian Armed Forces personnel ....................3                                  Relative Value Guide ..........................................8
      Department of Veterans' Affairs (DVA) ...............3                                 Reports to other third parties...............................9
      Medical Services Plan Sask. Health MS .............2                                   Students injured at school ..................................9
      Other provinces...................................................2                    Telephone advice................................................9
      Royal Canadian Mounted Police (RCMP) ...........3                                 Reports to lawyers .....................................................9
      Sask. Cancer Foundation (SCF) .........................2                          Verification of accounts to MSP .................................8
      Sask. Government Insurance (SGI) ....................2                            Visits and procedures.................................................7
      Sask. Health (Medical Services Plan) .................2
                                INTRODUCTION TO BILLING
                                 FOR PHYSICIAN SERVICES
                                   IN SASKATCHEWAN
                                                PREFACE

This document is part of a series produced by the Saskatchewan Medical Association for the benefit of its
members. Others in this series are:

1   Relative Value Guide To Physicians' Fees (RVG) which also contains:
    (a) The SMA Policy Statement on Third Party Requests and Uninsured Services; and the

    (b) Physician's Guide To Third Party Requests And Uninsured Services;

2   Correct Claims Corner published periodically in the SMA News;

3   Correct Claims Corners Consolidated; and

4   Member Advocacy and The Member Advisory Committee.


           THE CHALLENGE OF                             Office Accounting Systems
         FEE-FOR-SERVICE BILLING                        The fees for physician services are listed in the
                                                        Payment Schedule for Physician Fees which is
The Government of Saskatchewan operates a               described later in this document. A service code
publicly funded health care insurance system. It        number is assigned to each billable service
pays for the majority of physician services on a        listed in that schedule. Claims for physician
fee-for-service basis. To physicians who have           services are submitted to the appropriate
never billed for their services, entry into this        agency for reimbursement. It is essential that the
system can be an intimidating prospect.                 physician's office establish and maintain an
Awareness of the basics of the system can               efficient, workable accounting system which will:
alleviate the apprehension and can also avoid           1 record all expenses of the professional
the pitfalls which can entrap the unaware                    practice;
newcomer.
                                                        2   record all billings submitted;
         A PRACTITIONER'S OFFICE
                                                        3   record all payments received; and
Establishing An Office
Whether establishing a new practice, or                 4   reconcile the payments received with billings
assuming an existing one, the physician is well             submitted to identify unpaid claims.
advised to ensure that the office is:
1 conveniently located;                                 The physician who:
                                                        1 is establishing a new practice is advised to
2   comfortable with adequate space and a                  enlist appropriate accounting advice to
    convenient floor plan that ensures                     establish and maintain an adequate
    confidentiality; and                                   accounting system; and

3   adequately and personably staffed to                2   has assumed the practice from another
    handle:                                                 physician is advised to enlist appropriate
    (a) patient appointments and patient flow;              accounting advice to ensure that the existing
        and                                                 accounting system is adequate.

    (b) clinical charting and practice accounting.




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    INSURED SERVICES PAYING AGENCIES                       Saskatchewan Health (Medical Services):
                                                           It pays for:
The addresses of most of the paying agencies to            1 services related to sexually transmitted
whom accounts may be sent are listed in                         diseases; and
Section A.2 of the RVG.
                                                           2   reports to Social Services.
Medical Services Plan of
Saskatchewan Health (MSP)                                  Saskatchewan Cancer Foundation (SCF)
The MSP:                                                   The diagnosis and treatment of cancer are
1 is authorized by The Saskatchewan Medical                insured by the MSP but physicians are required
   Care Insurance Act                                      to register patients being treated for cancer with
                                                           a cancer clinic in Regina or in Saskatoon.
2    to insure most       services   provided    by        Requests for out-of-province treatment for
     physicians, but                                       cancer must be submitted to the SCF for prior
                                                           approval.
3    the legislation specifies which services are
     not insured under the Act.                            Reports to Cancer Clinics
                                                           Code 50A is paid for a report by an attending
Paying Agencies Of                                         physician that provides follow-up care for a
Other Provinces and Territories                            registered cancer patient who has been under
The provinces and territories of Canada,                   therapy by a Cancer Clinic. The Cancer
excepting Quebec, have an agreement for                    Foundation desires follow-up information at
reciprocal processing of out-of-province medical           specified intervals and requests the physician,
claims. For an insured service provided to                 usually a family physician, to provide a report.
residents of other provinces and territories, the          This obviates the need for rural residents to
claim is submitted to the MSP in the usual way             travel to a cancer clinic in Regina or Saskatoon
and the MSP then reconciles with the respective            for review. The physician may also claim an
home province or territory. The Payment                    examination fee if the patient has been recalled
Schedule lists on page I.27 some instructions on           and assessed for the purposes of that report.
how to enter the patient identification numbers.
Payment will be made at Saskatchewan rates                 Workers' Compensation Board (WCB)
which must be accepted as payment in full. A               The WCB is:
record of name, address, sex, date of birth, head          1 authorized by The Workers' Compensation
of household, health insurance number and its                 Act, to
expiry date should be kept in case there are
questions about the account.                               2   insure services required for work-related
                                                               injuries and illnesses.
If the patient cannot produce a health services
card from the home province, physicians have               The MSP has a cross-link with the WCB and
the option of billing either the patient directly or       returns to the physician any account which may
the home province plan using the Out-of-                   be for a work-related injury or illness. The
Province Claim Form. Legislation requires that             General Information section of the Payment
all persons, including First Nations people, must          Schedule describes the process on page I.21.
register every time they move to a new province
or re-enter a previous home province.                      Reports to WCB
                                                           The WCB pays physicians for reports at rates
Some services are excluded from this reciprocal            negotiated with the SMA and these are listed in
billing program. These are generally services              Section A.2 of the RVG.
which are uninsured in at least one provincial
jurisdiction and they are listed along with further        Saskatchewan Government Insurance (SGI)
information in Appendix A under the General                The MSP pays for insured medical services
Information section of the Payment Schedule.               required as a result of motor vehicle accidents.
Out-of-Province patients should be billed directly         The SGI is authorized by The Automobile
for these services.                                        Accident Insurance Act to pay for examinations
                                                           and reports by physicians provided for third
                                                           party liability claims.



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Reports To SGI                                                 2    are not entitled to any fee if they have
SGI pays directly for reports at rates negotiated                   not provided a service except as
with the SMA and these listed in Section A.2 of                     outlined below for supervised services.
the RVG. Reports should be sent directly to SGI
which recognizes only those reports which one              Supervised Services
of its assessors or agents has requested.                  Payment will be made for:
                                                           1 services provided by house staff under a
Lawyers are not entitled to request SGI reports.              physicians' supervision or if the physician is
Nevertheless, some lawyers do ask that                        available to intervene at any time if needed;
physicians send the completed SGI report form                 and for
to their offices. The law is quite clear. Section 72
of The Automobile Accident Insurance Act                   2   certain services provided by a physician's
specifies that the report must be sent to the                  office staff, a list of which is on page I.17 of
offices of SGI. Lawyers should be directed to                  the Payment Schedule.
obtain copies of medical reports from SGI if
they really need them.                                     Billing More Than One Agency
                                                           During a visit for a work-related condition for
Department of Veterans' Affairs (DVA)                      which the WCB has taken responsibility, the
The DVA pays for physician services provided to            patient may ask the physician to assess a
war veterans who have DVA pensionable                      common cold. It is not appropriate to bill WCB
disabilities. The rates are listed in Section A.2 of       for the management of the compensable
the RVG.                                                   condition and also bill the MSP for assessing the
                                                           cold at the same visit. The MSP has a linkage to
Canadian Armed Forces Personnel                            WCB cases and will reject all such dual claims.
The Canadian Forces Bases at which military
personnel are stationed pay for services                   Services To Own Family
provided to armed services personnel.                      The Council of the College of Physicians and
                                                           Surgeons has declared it unethical for a
Royal Canadian Mounted Police (RCMP)                       physician to bill a third party for services
The Force pays for physician services provided             provided to self, spouse or children. We can also
to RCMP personnel.                                         take a page from legal parlance which holds that
                                                           lawyers who conduct their own defense have
     SOME GENERAL C0NSIDERATIONS                           fools for clients.
            ABOUT BILLING
                                                           Referrals by Physicians to Specialists
Guiding Principles                                         When a physician has referred a patient to any
When submitting claims for         professional            specialist for consultation, that consultant is
services to any insuring agency or to any other            entitled to bill at the specialist rates listed in the
third party physicians should be guided by the             appropriate specialty section of the Payment
following principles:                                      Schedule.

•   establish the fee as if the patient were being         Referring Patients Outside The Province
    asked to pay it; and                                   Most services provided outside Saskatchewan
                                                           to Saskatchewan beneficiaries are paid by the
•   the fee should not be such that one’s                  MSP at host province rates if reciprocal billing or
    medical colleagues would have difficulty               at Saskatchewan rates if directly billed to the
    defending it if it should be disputed.                 patient. Services which are not available in
                                                           Saskatchewan may be paid at special rates if
No Show, No Dough                                          the MSP agrees with the referral in advance.
Physicians:                                                The process of obtaining that approval is stated
   1 are entitled to a reasonable fee for every            on page I.5 of the Payment Schedule.
        service that has been personally
        provided;




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Family Physician Consultants                             Locum physicians who have been issued a
1 When a family physician consults with                  temporary license and who intend to practice in
   another family physician, a reasonable                Saskatchewan for more than 11 months are
   explanation is required. The rules here are           eligible to obtain a MSP billing number which
   not clearly stated but the assessment                 allows them to submit claims to, and be paid
   practice is that the condition of the patient         directly by, the MSP.
   must warrant the consultation.
                                                         Modes of Billing
2   It does not seem reasonable to charge a              The legislation provides physicians three options
    consultation when one family physician               of billing for insured services but, in practice, the
    helps an associate make the diagnosis of             first one is the only realistic one. The options
    chicken pox.                                         are:

3   It is reasonable to expect that family               Mode 1
    physician associates will consult, from time            Submit all accounts directly to the MSP.
    to time, in the interests of good patient care          The physician is asked to sign a Mode 1
    and for the diagnosis and/or management of              Agreement which specifies that the
    critical illnesses, such as an acute abdomen.           physician will accept the MSP rates as
                                                            payment in full.
Referral to Consultants
Payment is made at the relevant specialty rates,         Mode 3
including consultations, when the patient has               Submit accounts to the patient with enough
been referred:                                              information to allow the patient to obtain full
1 to a physician by another physician;                      reimbursement from the MSP. This means
                                                            that the fees charged the patient must not
2   to a specialist by an optometrist;                      be more than is paid by the MSP.

3   to a specialist in orthopedics, plastic              Outside the Act
    surgery,   otolaryngology,   neurosurgery,              A physician may bill patients directly outside
    neurology or dermatology by a dentist; and              the Act provided that:
                                                            (a) it applies to all patients and to all
4   to a specialist by a chiropractor.                           services;

           THE BILLING PROCESS                               (b) access to services is not jeopardized;
                                                                 and that
Registration for Billing
When a physician has become fully licensed by                (c) each patient is advised in advance that
the College of Physicians and Surgeons, the                      the services are not insured and that the
College submits that physician's name to the                     patient is not entitled to reimbursement.
Medical Services Plan Saskatchewan Health in
Regina. The MSP then assigns each physician a            Insufficient Postage On Claims
billing number which that physician must then            Canada Post's policies state that:
use on all claims submitted to the MSP.                  1 mail with insufficient postage is returned to
                                                             the sender;
Locum Tenens
Locum physicians who are fully licensed must             2   if no return address is shown, a notice will
bill under their own billing number. Payments                be sent to the person to whom it was
are made to that locum physician.                            addressed;

Locum physicians who have a temporary license            3   the addressee can pick up the mail on
for up to 11 months must bill under the billing              payment of the outstanding postage; and
number of the fully licensed physician whom
they are replacing. Payments are made to that            4   any mail not picked up will be destroyed
fully licensed physician and the locum is paid in            after a period of time.
accordance with the contract between the two
parties.



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The MSP will pick up mail when it receives a             Selecting Appropriate Service Codes and
notice of insufficient postage but the system is         Fees
not foolproof. Physicians should consider                A typical family practice day could have a mix of
investing in a postal scale to ensure that their         the following visit services in the office:
postage is adequate.
                                                         Type of Service                  Service Code
Time Limit on Accounts                                   Complete assessment
To be eligible for payment, claims for insured               - under age 65                       3B
services must be received by the MSP within six              - age 65 or older                    2B
months of the date of service. That time limit           Partial assessment
may be extended to 12 months if the physician                - under age 65                       5B
can convince the MSP that the delay was                      - age 55-64                          7B
caused by very special circumstances beyond                  - age 65 or older                    6B
the physician's control: not easily done! The best       Prenatal visit                           8B
plan is to submit accounts regularly as soon as
possible after the services have been provided.          Well baby care                           4B

The Payment Schedule                                     Consultation                             9B
The schedule of fees is published by the Medical
Services Plan as a Payment Schedule For                  Counselling
Physician Service. Its current form grew out of                 - first 15 minutes                40B
negotiations between the Medical Service Plan                   - each subsequent 15 minutes      41B
and the Saskatchewan Medical Association, a
process provided for in legislation. The Payment         Physicians who attend hospital in-patients will
Schedule is amended periodically in accordance           claim daily hospital care under 25B to 28B
with agreements reached between those two                depending on the number of days the patient
parties.                                                 remains an inpatient. Claims for newborn care in
                                                         hospital are based on 30B-32B or 30-32C.
The Schedule is divided into Sections. Section A
lists service code numbers and fees for some             Claims for visit services provided by a physician
General Services, Section B lists service code           who must make a special trip from home or
numbers and fees for office services by Family           office to the Hospital, the Special Care Home or
Physicians, Section H does the same for                  the patient's home are most often billed as the
Anaesthesia, Section J for Surgical Assist               appropriate visit code, 5B, 6B or 7B, plus a
services, Section L for General Surgery, Section         surcharge. Surcharges are described later in this
P for Obstetrics & Gynecology, and there are             document.
other sections for the other specialties.
                                                         Family Physicians who practice obstetrics will
Physician services listed in the Schedule are            find the service codes and fees for those
considered to be divided into three main                 services in Section P of the Payment Schedule.
categories: Visits, Procedures, and Diagnostic           Code 41P is the code for a vaginal delivery by a
Services.                                                Family Physician.

New Procedures                                           Codes and fees for:
Under legislation, a physician service is not            1 excision of lesions and repair of lacerations
insured if it is not listed in the Payment                  are in the 857L - 898L series of Section L;
Schedule. The service codes and fees for new
procedures and services are part of the                  2   anaesthetic services are listed in Section H;
negotiations between the MSP and the SMA. To
initiate the introduction of a fee for a new             3   surgical assists in Section J; and
service, the best route is to ask the
representative of the specialty section to make a        4   laboratory diagnostic tests provided in the
submission to the SMA whereupon it will follow               Family Practice office, are listed in Section
the appropriate channels.                                    V.




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Submission Of Claims to Insuring Agencies                 1   becoming familiar with the payment rules in
Claims for insured services submitted to the                  the Payment Schedule;
MSP must contain the patient's name, address,
date of birth and Health Services Number along            2   billing according to those rules;
with the service code and fee for the service
being claimed. All claims to the MSP are to be            3   relying on experienced office billing clerks
submitted electronically by computer. The MSP                 and on advice from colleagues BUT taking
requirements for automated billing are given in               care to check with the SMA if any such
the General Information section of the Payment                advice seems to be questionable;
Schedule. A list of approved billing software
vendors can be obtained from the MSP or from              4   remembering that the claim submitted is
the SMA.                                                      their responsibility; physicians cannot
                                                              escape that responsibility by hiding behind
When submitting a claim for an insured medical                the billing clerk's errors;
service to any paying agency, the following
points are important:                                     5   memorizing the service codes of the visit
1 the claim must be accurate;                                 and procedure services that they most
                                                              commonly provide;
2   it is the physician's responsibility to ensure
    the accuracy of all claims;                           6   communicating to the billing clerk the
                                                              appropriate code and fee for every service
3   a claim may be submitted for each service                 rendered;
    provided as listed in the Payment Schedule;
                                                          7   verifying that the office billing procedures
4   a claim must never be submitted unless an                 are correct;
    insured service was provided;
                                                          8   being aware that The Medical Profession
5   the billing clerk must not be left to guess               Act deems it unprofessional conduct to
    what the appropriate service code should be               submit claims for services that were not
    for any service and so care must be taken to              rendered;
    clearly communicate to the office billing clerk
    the service code for each insured service to          9   ensuring that the name, Health Services
    be claimed; and                                           Number, date of birth and sex of the patient
                                                              for every claim match or the claim will be
6   payments by the other paying agencies are                 automatically rejected; and
    also based on the MSP Payment Schedule.
                                                          10 submitting a written explanation to the
The Diagnosis on Claims                                      Medical Consultant when a procedure is not
1 Legislation requires that each claim have a                listed in the Payment Schedule, or when
   diagnosis but the MSP computer system can                 services to a patient involved unusual skill,
   accept only one diagnosis per claim.                      time or attention.

2   Physicians should be attentive to the                 Reports To MSP and Confidentiality
    diagnosis submitted and avoid simply using            MSP medical consultants may ask a physician
    the diagnosis from the previous visit if it was       for a report on a complex case to help them
    really different. If the diagnosis and the            understand the claim submitted and to assess it
    treatment don’t match, the JMPRC might                fairly. The frequency of these can be minimized
    ask for an explanation.                               by sending an explanation with the claim.
                                                          Submitting clinical information does not
3   On automated claims submissions, the                  constitute a breach of confidentiality because
    ICDA code is required.                                the Act provides protection for providing
                                                          information for the purposes of administering the
Minimizing Billing Errors                                 Act. Furthermore, the Act binds the MSP
Billing errors will occur but physicians can              employees to secrecy.
minimize them by:




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Billing MSP For Reports - In Error                      in the Schedule. The 42 beside a fee means
Sometimes a consultant assesses a patient,              that the fee includes all services related to the
sends a report to the referring physician and           procedure by the surgeon on the day of surgery
submits the claim to the MSP only to discover           and 42 days thereafter. The A 10 beside a fee
later that the reason for the referral was at the       means that the fee includes services related to
request of an insurance company, or for medico-         the procedure on the day of the procedure plus
legal reasons. In such instances, the MSP               any on the ensuing 10 days. The 42 day
should be advised of the error so that the              procedures are most often performed by
incorrect payment can be recovered. The                 specialists. The 10 day procedures include
embarrassment of such errors can be avoided             treatment of skin lesions and skin biopsies. The
by clear communication between the office of            0 day category includes procedures such as
the referring physician and that of the                 injections.
consultant.
                                                        Visits and Procedures
 EXPLANATORY CODES FOR PHYSICIANS                       The essential point of visit and procedure rule is
                                                        that when a visit is made on the same day as a
The Explanatory Codes are included in the               0 day or 10 day procedure, the fee payable is
Payment Schedule. When a physician receives             the greater of:
payment from the MSP, any rejected claim has            1 the fee listed for the procedure; or
an alphabetic code beside it such as AA, AB,
AC, etc. That code appears in the Explanatory           2   the sum of the visit fee plus 75% of the fee
Code section of the Payment Schedule and                    listed for the procedure.
beside it is the reason for the rejection. There
are many reasons ranging from misidentification         3   Visits are not paid for services related to the
of the patient, to a duplicate claim, to WCB                procedure during the post op period of a 10
responsibility, to the service not being insured,           day or 42 day procedure.
or failure to observe some payment rule. The
physician who pays attention to the explanatory         Concurrent Procedures
codes can learn many aspects of appropriate             The main rule for this group of services is that
billings.                                               when two or more 10 day or 42 day procedures
                                                        are done on the same day, payment is based on
                                                        the higher procedure at 100% and the others
      GENERAL ASSESSMENT RULES                          each at 75% of the listed fee.

The Payment Schedule lists a series of complex          Where Surcharges Apply
and interlinked assessment or payment rules             A surcharge is a fee paid in addition to the fee
which need to be well understood by all                 for a professional service provided on a priority
physicians in order to use the Schedule                 basis where the physician has to make a special
appropriately. For family physicians, perhaps the       trip with some disruption to the physician to
most important of these are the composite fee           provide that service. The service codes and fees
and the multiple services rules.                        for surcharges are listed in the 815A - 839A
                                                        series of the Payment Schedule. The payment
The Composite Fee                                       rules that apply are also explained there. The
The composite fee is a concept that has been in         appropriate service code and fee depend on the
physician fee schedules since their earliest            time of day and the day of the week. Surcharges
beginnings across Canada. The underlying                may be claimed for visit as well as procedural
concept was that the fee for a surgical                 services. The surcharge service code must be
procedure, such as an appendectomy, included            included with the claim submitted for the
the surgery and the post-operative care.                applicable service.

"0" and "10" Day Rules                                  Surcharges are claimable along with premiums.
The Payment Schedule has refined the
composite fee concept. It has divided surgical          Out-of-Hours Premiums
procedures into 42 day, 10 day and 0 day                A premium is a fee paid in addition to the fee for
categories. The category is stated beside each          a professional service provided outside the
surgical fee and beside selected procedure fees         physician's office between the hours of 5:00 p.m.



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and 7:00 a.m. on week days and at any time on            1   should be made quickly, honestly and
weekends and on statutory holidays. Premiums                 courteously;
are described in Section A of the Payment
Schedule      under     a     separate    heading:       2   often need only a statement that the service
Out-of-Hours Premiums. The payment rules list                is noted in the clinical records;
some exceptions: surcharges, services always
provided in the office, hospital and special care        3   may require that the service be described in
home visits plus others. Otherwise, the premium              more detail; and
applies to all visit and procedure services. The
amount paid as a premium is a negotiated                 Physicians should never ask their patients to
percentage of the fee for the service provided. It       change their verification responses to MSP.
is one level for services provided between 5:00
p.m. and midnight and a higher level for services        The outcome of these verifications is seldom of
provided between midnight and 7:00 a.m. The              any consequence but:
premium for an obstetrical delivery depends, not         1 some disagreement patterns are referred to
on when the physician arrived at the delivery                the JMPRC; and
suite, but on the time of the actual delivery. For
other services, the level of the premium depends         2   in some cases, following explanation by the
on when the procedure begins.                                physician, the fee is adjusted from a
                                                             complete assessment to the appropriate
The claim for a premium must give the place of               partial assessment.
service (In-hospital, out-patient home or other),
and the type of eligible premium. The fee for the            THE JOINT MEDICAL PROFESSIONAL
premium is not to be included in the claim. The                 REVIEW COMMITTEE (JMPRC)
Medical Services Plan computer system
calculates the appropriate premium and makes             The MSP, the College of Physicians and
the payment automatically.                               Surgeons and the SMA each appoint two
                                                         physicians to the JMPRC. Its function is to
Premiums are claimable along with surcharges.            review those billings by physicians that seem to
                                                         be aberrant. If the committee deems that the
        VERIFICATION OF ACCOUNTS                         billings submitted by a physician have been
          SUBMITTED TO THE MSP                           inappropriate, the Act empowers the committee
                                                         to reassess those claims. That means that the
The process is this:                                     physician is asked to repay a portion of the
1 the MSP verifies routinely about two percent           amount paid by the MSP during a previous
   of visit services to ensure that payments             period of not more than 15 months which the
   from the public purse are appropriate, a              committee has specified as being under review.
   process which the SMA has accepted as a               That decision is enforceable under the law and
   necessary evil;                                       may be appealed to the Courts.

2   additional special verifications of services                    APPEAL PROCEDURES
    such as 3Bs and surcharges are done on
    specific criteria.                                   An appeal process is described in the General
                                                         Information section of the Payment Schedule. It
3   patients are asked to return a form if they          is available to physicians who wish to appeal
    think a stated service was not provided and          any assessments of their claims by the MSP.
    the physician is asked to respond to any             The method of appealing rulings of the JMPRC
    patient disagreement;                                to the Courts is outlined in the legislation.

4   the physician, the College and the SMA are                      UNINSURED SERVICES
    notified of any special verification being
    undertaken.                                          The Relative Value Guide (RVG)
                                                         The RVG mirrors the MSP Payment Schedule
Responses to inquiries from the MSP about                and lists relative value units which the SMA's
such disagreements:                                      committees on fees would like to see reflected in
                                                         the Payment Schedule. Section A of the RVG



                               CONTACT SMA FOR CLARIFICATION
                                                      9


also contains relative value units for many               1   health status reports,
uninsured services to guide physicians in
establishing their fees for such services. It is          2   certificates of fitness to drive;
contrary to federal competition legislation to fix
fees, and thus the RVG is not binding upon                3   insurance medicals;
physicians. However, it is well for physicians to
keep in mind that third parties and individual            4   copies of consultation reports; or
patients often rely on the RVG when contesting
the level of a fee charged by a physician. The            5   reports of any kind to a third party.
SMA's Member Advisory Committee is
sometimes called upon where a private fee is              Some physicians have found that their patients
being disputed.                                           shop around until they find a physician who does
                                                          charge for these services but rather bills the
Billable Uninsured Services                               MSP. The SMA Board of Directors asks that we
Uninsured Services for which a physician is               all respect the law and charge the patient or the
entitled to charge the patient directly include:          third party directly for such reports and their
1 medical reports;                                        requisite assessments. Further information on
                                                          this topic is found in the SMA's Guide to Direct
2   drugs and dressings;                                  Billing.

3   telephone advice;                                     When acting on behalf of a third party, it is wise
                                                          be sure that the patient understands a
4   plastic surgery for cosmetic purposes.                physician's legal responsibility to that third party
                                                          before proceeding with the examination. The fee
Accounts for uninsured medical services are               for such service should always be discussed
submitted on the physician's own Statement of             with the patient before proceeding.
Account. In selecting appropriate fees for private
billing, physicians are advised to refer to Section       Students Injured at School
A of the SMA’s Relative Value Guide to                    The medical care provided to a pupil injured at
Physicians' Fees. For more details about                  school is covered by the MSP. Completion of the
uninsured services, consult the Physician's               "student accident insurance form" is not an
Guide to Third Party Requests and Uninsured               insured service. Payment for this form is
Services.                                                 therefore the responsibility of the patient or the
                                                          insurance company. It appears from our
Reports To Lawyers                                        correspondence that Seaboard Life is willing to
It is always prudent to comply with requests for          provide up to $15.00 to offset the physician's fee
medico-legal reports so long as the patient has           for form completion. The invoice may be
given     informed    consent.    Lawyers      will       submitted along with the claim form to:
occasionally request a copy of the entire clinical            Seaboard Life Insurance Company
chart. Legal precedents have become such that,                Claims Department
                                                                             st
if the patient understands the implications and               2050 - 777 – 81 Avenue SW
consents to a transfer of the chart's total                   Calgary, AB T2P 3R5
contents to the lawyer, then the physician has
no option but to comply. It is wise to always             Uninsured Advice by Telephone
clarify with the lawyer what the legal                    Telephone advice to patients is not an insured
requirements for information are. When the legal          service but nothing prevents a physicians from
requirements are clear, it is much easier to help         charging the patient privately for it. If a charge is
the lawyer act in the interests of the                    to be made for medical advice by telephone, the
patient/client.                                           physician should advise the patient it is not
                                                          insured and to expect a bill.
Reports To Other Third Parties
A third party service is defined as any service           Consulting with house staff or a casualty officer
provided for a patient which is necessary to              is bound by the same fate; it is not insured.
satisfy the requirements of a party other than the
patient. The legislation is clear that the MSP
does not insure third party requests for:



                                CONTACT SMA FOR CLARIFICATION
                                                   10


           HELP FOR PHYSICIANS                          Correct Claims Corner (CCC)
                                                        The SMA News periodically answers questions
Member Advisory Committee (MAC)                         that plague physicians about the fee schedule.
The SMA appoints a Member Advisory                      The CCC seeks to clarify the complex and
Committee which has the responsibility of               vague payment rules in the Payment Schedule
assisting physicians who are under investigation        and other questions that physicians have about
by any investigative body such as the College           appropriate billing. Physicians are invited to
and the JMPRC. The committee acts only when             contact the SMA with their questions about
asked by the physician for assistance.                  billing or concerns about the assessment of their
Physicians who receive notice from the JMPRC            accounts.
that their billings are under review are well
advised to contact the MAC through the SMA              The document entitled Correct Claims Corners
office.                                                 Consolidated compiles the CCC items published
                                                        in the past and is a valuable reference for those
Details about the structure and procedures of           details about billing which are beyond the scope
the MAC are contained in a document entitled            of this document.
Member Advocacy and The Member Advisory
Committee.




                              CONTACT SMA FOR CLARIFICATION

								
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