Understanding Audits: The chiropractor’s guide to administrative compliance
Welcome to Understanding Audits! We developed this resource as a supplement to ourUnderstanding Extended Health Careguide. It’s intended to help you proactively manage your practice to minimize the difficulty and inconvenience of an audit. We’ve also included some information and tips to assist you if this happens.
The purpose of this tool is to provide background information for you as an Ontario Chiropractic Association (OCA) member. It is not a substitute for legal advice.
What is an EHC Audit?
Extended Health Care (EHC) coverage is an employee benefit paid for by employers (plan sponsors) and administered by the life and health insurance industry. Insurers administer this coverage according to terms and conditions set out in plan contracts with employers.
Insurance companies specifically design contracts to allow them to request additional information from patients and their health care professionals. This is a standard condition of reimbursement for insured products and services. These requests for further information are sometimes known as audits.
An audit may be minor, such as a routine claim verification, or it may be more serious and comprehensive (e.g., involve an investigation).
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“The objective of an audit is to establish that the services were provided to the patient and that the claim is eligible according to the terms of the contract.¹”
Most of the time audits are routine and quickly resolved. However, if an audit reveals a lack of compliance with theCollege of Chiropractors of Ontario’s (CCO)standards of care and/or insurers’ policies, this can have serious consequences. These may include financial penalties (e.g., claims repayment), administrative action by the insurer, and/or disciplinary action by the CCO. In extreme cases, an insurer may decide to permanently delist you, and possibly your entire clinic. This means that you and your patients will no longer be eligible to bill or submit claims to that insurer.