Fee-for-Service: Bill Confidently and Reduce Audit Risk
MSP processes more than 100 million claims each year, and the default is to pay what is submitted. However, being paid for a service does not mean the billing was done correctly. Audits could be triggered by billing patterns, inconsistencies, or randomly, and can uncover issues after the fact.
You are accountable for every claim:
It is your responsibility to ensure that all claims submitted to MSP on your behalf are accurate and supported by appropriate documentation, even if your staff, MOA, or a third‑party billing company submits billings.
Here are a few practical steps you can take to reduce fee-for-service audit risk:
1. Use primary sources, not assumptions
- Read the preamble and fee notes in the latest MSC Payment Schedule ↗ as many issues happen because a preamble condition or fee rule wasn’t met
- Use our Simplified Fee Guide regularly to easily see relevant and connected rules and recent updates:
- We list most relevant Preamble Excerpts for family doctors
- We update and describe fees codes to include:
- Up-to-date fee notes
- Links to other relevant fees
- Billing tips
- Common FAQs
- Stay up to date by reading our Billing Alert emails or checking Billing News to learn about early fee changes and additions before they appear in the official MSC Payment Schedule
- See our Uninsured Services Package and Tutorial to correctly bill for services not covered by MSP
- Do not rely on MSP to tell you when something is wrong
- Do not rely on EMR prompts
- Be cautious with billing advice from colleagues or private billing companies
2. Document like an auditor will read it
Document the full story clearly: what you billed, why it was medically necessary, and how the fee criteria were met. Clear documentation allows you to explain and defend your billing if it is questioned, helps resolve rejections and refusals, and reduces the likelihood that an audit will result in repayments.
- See Preamble C. 10. Adequate Medical Records of a Benefit under MSP
- Record start and end times for all time‑based fees
- For planning fees, name the eligible diagnoses and describe the complexity that made the care plan necessary (e.g., complex care 14033, mental health planning 14043)
- For a complete physical exam, document all examined systems and why it is clinically indicated (Preamble D. 3. 1.)
- Do not destroy appointment records
3. Don’t try to “make a fee fit”
Trying to force a service into an existing fee code that does not fully meet the fee criteria could be an audit risk. If no existing code applies, consider using Miscellaneous Fee Code 00199 for a medically necessary insured service that is not listed in the MSC Payment Schedule. This fee does not have a set amount and requires careful documentation and fee estimate.
Under Preamble C. 4 Miscellaneous Services, 00199 could be used for:
- New or uncommon medically necessary service that is a standard of care and not experimental
- Unusually complex procedures
- Unlisted “team” procedures
- A service where you believe MSP should give independent consideration to payment, such as a procedure that was attempted but not completed due to unforeseen circumstances
Uninsured services
If a service is not insured by MSP, you should not bill 00199. Instead, bill the patient or third party directly using the appropriate uninsured fee. Uninsured services are:
- Not medically necessary
- Provided for administrative, legal, or third‑party purposes (most forms, notes, or reports for employers, insurers, schools, or legal matters)
4. Pay attention to common issues
- Do not bill for yourself or family members, even for a simple immunization (Preamble C. 19. Services to Family and Household Members)
- Ensure the patient’s age matches the fee code category
- Verify that patient PHN and DOB are correct
- For newborns without PHN: use mother’s PHN with “66” and only during the month of birth + 2 months.
- Use correct diagnostic ICD-9 codes that match requirements (e.g. chronic disease management fees 14050, 14051, 14052, 14053)
- For multiple procedures in a same visit, bill the highest value at 100% and additional at 50% unless otherwise specified (Preamble D. 7. c)
- Review your Doctors of BC Mini Practice Profile annually and make sure you can address any red flags and outliers
- Review your remittances twice a month and if something doesn’t look right, contact MSP ↗ and document their advice: who, what, and when
Resources
- Audit and Adjudication PDFs
- Uninsured Services Package with invoice templates
Non-Certified Mainpro+® Credits
Learning about billing meets CFPC criteria for Mainpro+® non‑certified credits. Claim time-based credit (e.g., ~15 minutes = 0.25 credit) for a reading activity, categorized as a practice management topic designed to increase physician knowledge of billing in a practice setting. Self‑report via CFPC.
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