Extra Billing and Balance Billing

“Extra Billing” means billing an amount over the amount payable for an insured service (a “benefit”) by MSP. Extra billing is not allowed under the Medicare Protection Act except for services rendered by medical practitioners who are not “enrolled” with MSP (i.e., no services are covered by MSP) and then only for those services which are rendered outside of hospitals and community care facilities. 

“Balance billing” denotes the practice of medical practitioners who are opted in under MSP billing MSP for the MSP fee and the patient for the amount of the difference between the payment made by MSP for an insured service and the fee for that service listed in the BCMA Guide to Fees, under the heading “BCMA Fee.” Except as defined by differential billing for non-referred patients above, balance billing is not permitted under the Medicare Protection Act.

Differential Billing for Non-Referred Patients

If a specialist attends a patient without referral from another practitioner authorized by the Medical Services Commission to make such referral, the specialist may submit a claim to MSP for the appropriate general practitioner visit fee and in addition may charge the patient a differential fee. This is not considered “extra billing.” 

The maximum amount the patient may be charged is the difference between the amount payable under the General Practice Payment Schedule for the service rendered, and the amount payable under the Payment Schedule to the specialist had the patient been referred.

Missed Appointments

Claims for missed appointments must not be submitted to MSP. Billing the patient directly for such missed appointments would not be considered extra billing.

Payment for Specialist Consultations/Visits and specialty-restricted items 

To be paid by MSP, ICBC or WorkSafeBC for specialist consultations, visit items and/or other specialty-restricted fee items listed in the specialty sections of the Payment Schedule, one must be a Certificant or a Fellow of the Royal College of Physicians and Surgeons of Canada and/or be so recognized by the College of Physicians and Surgeons of British Columbia in that particular specialty. 

A specialist recognized in more than one specialty by the College of Physicians and Surgeons of British Columbia should bill consultation and referred items under the specialty most appropriate for the condition being diagnosed and/or treated for that referral/treatment period.

Reciprocal Claims

All Provinces, and Territories, except Quebec, have entered an agreement to pay for insured services provided to residents of other provinces when a patient presents with a valid Provincial Health Registration Card. Claims can be submitted electronically and details of this process may be obtained by contacting MSP. However, the services listed below are exempt from this agreement and should be billed directly to the non-resident patient.

Medical Practitioner Services Excluded under the Inter-Provincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims 

1. Surgery for alteration of appearance (cosmetic surgery)

 2. Gender-reassignment surgery 

3. Surgery for reversal of sterilization 

4. Routine periodic health examinations including routine eye examinations (including PAP tests for screening only) 

5. In-vitro fertilization, artificial insemination 

6. Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy 

7. Services to persons covered by other agencies; Armed Forces, WorkSafe BC, Department of Veterans Affairs, Correctional Services of Canada (Federal Penitentiaries) 

8. Services requested by a “Third Party” 

9. Team conference(s) 

10. Genetic screening and other genetic investigation, including DNA probes 

11. Procedures still in the experimental/developmental phase 

12. Anesthetic services and surgical assistant services associated with all of the foregoing.

The services on this list may or may not be reimbursed by the home province. The patient should make enquires of that home province after direct payment to the BC medical practitioner

Assignment of Payment

An “Assignment of Payment” is a legal agreement by which an attending practitioner designates payment for his/her services to another party. In this circumstance, the designated party may use the attending practitioner’s practitioner number in combination with its own payment number when submitting claims to MSP. To authorize MSP to make payment to a designated party, the attending practitioner must complete and file an “Assignment of Payment” form. However, even though the payment has been assigned, the responsibility for the clinical service and its appropriate billing remains with the practitioner whose practitioner number is used.

Adequate Medical Records of a Benefit under MSP

Except for referred “diagnostic facility” services, a medical record is not considered adequate unless it contains all information which may be designated or implied in the MSC Payment Schedule for the service. Another medical practitioner of the same specialty, who is unfamiliar with both the patient and the attending medical practitioner, would be able to readily determine the following from that record at hand:

a. Date and location of the service.

b. Identification of the patient and the attending medical practitioner. 

c. Presenting complaint(s) and presenting symptoms and signs, including their history. 

d. All pertinent previous history including pertinent family history. 

e. The relevant results, both negative and positive, of a systematic enquiry pertinent to the patient’s problem(s).

Process

Where such a new therapy or procedure is being introduced into British Columbia and the medical practitioners performing the new therapy or procedure wish to have a new fee item inserted in to the fee schedule to cover the new therapy or procedure, the process to be used is as follows:

An application for a new fee item related to the new therapy or procedure will be submitted by the appropriate section(s) of the BCMA to the BCMA Tariff Committee for consideration, with documentation supporting the introduction of this item into the payment schedule. The BCMA Tariff Committee will advise the Medical Services Commission whether or not this new therapy constitutes experimental medicine. If the Tariff Committee considers that the item is experimental, it will not be considered an insured service and will not be introduced into the fee schedule. If the Medical Services Commission, on the advice of Tariff Committee, determines that the new therapy or procedure is not experimental medicine, the fee item application will be handled in the usual manner for a new fee.

When a new therapy or procedure is being performed outside British Columbia, a patient or patient advocate may request that the services associated with this new therapy or procedure be considered insured services by MSP. The situation will be reviewed by the Medical Services Commission utilizing information obtained from various sources, such as medical practitioners, the BCMA or evidence based research. If it is determined that the new therapy or procedure is experimental, then the cost of medical services provided for this type of medical care will not be the responsibility of MSP. If it is considered that the therapy or procedure is not experimental, the cost of medical services associated with this treatment will be in part or in whole the responsibility of MSP.

MSP Billing Number

A billing number consists of two numbers - a practitioner number and a payment number. The practitioner number identifies the practitioner performing and taking responsibility for the service. The payment number identifies the person or party to whom payment will be directed by the Medical Services Plan (MSP). Each claim submitted must include both a practitioner number and payment number.

Inclusive Services and Fees

If it is not medically necessary for a patient to be personally reassessed prior to prescription renewal, specialty referral, release of laboratory results, etc., claims for these services must not be made to MSP regardless of whether or not a medical practitioner chooses to see his/her patients personally or speak with them via the telephone.

Some services listed in the MSC Payment Schedule have fees which are specifically intended to cover multiple services over extended time periods. Examples are most surgical procedures, the critical care per diem listings and some obstetrical listings. The preambles and Schedule are explicit where these intentions occur. 

When, because of serious complications or coincidental non-related illness, additional care is required beyond that which would normally be recognized as included in the listed service, MSP will give independent consideration to claims for this additional care, if adequate explanation is submitted with the claim.