How to Avoid an Audit from an Extended Health Insurer: A Primer for RMTs
How to Avoid an Audit from an Extended Health Insurer: A Primer for RMTs
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An audit by an extended health benefits insurer can be an extremely invasive and stressful process for a Registered Massage Therapist (RMT). These audits also carry significant potential consequences, including demands for repayment, being de‑listed by the insurer, termination from employment (if applicable) and a complaint to the College of Massage Therapists of Ontario (CMTO).
In this article, I will outline the top seven triggers that lead insurers to initiate an audit into the billing practices of an RMT.
- Statistically Abnormal Billing Volume
Insurers routinely use sophisticated software programs to compare an RMT’s billing patterns against those of other RMTs in similar practice settings.
Common red flags include:
- Exceptionally high daily patient volumes
- Large annual billings to a single insurer
- Consistently billing more than 8-10 hours per day
While none of these factors necessarily indicate wrongdoing, they often prompt further scrutiny and can result in an audit being initiated.
- Other Unusual Billing Patterns
In addition to overall volume, insurer algorithms are designed to detect anomalies in billing patterns, such as:
- Identical billing amounts at every visit
- Repeated use of the same combination of services
- Very frequent treatment over extended periods (i.e. three to four visits per week for several months)
- A high percentage of claims reaching policy maximums, whether for services or medical devices
- Billing from multiple clinics on the same day
As artificial intelligence tools continue to evolve, the ability of insurers to analyze billing behaviour in greater depth will only increase.
- Billing Errors and Inappropriate Claims
One of the fastest ways to trigger an audit is through the submission of claims that are non-compliant, incomplete or otherwise deficient. Common examples include:
- Submission of claims for incorrect service types
- Claims submitted outside coverage limitations
- Submission of claims in the names of unauthorized service providers
- Rendering of receipts that do not contain all requisite information
For this reason, it is critical that RMTs and their staff members receive thorough and ongoing training regarding compliant billing practices. Ultimately, the RMT remains responsible for what is submitted under their name, whether they are the owner/operator of the clinic or simply work there as an employee or independent contractor.
- Patient Complaints
A complaint from a patient is an almost certain pathway to an insurance audit. Common complaints include allegations that:
- A service was billed but not provided
- Billing was excessive or inappropriate
- The clinic engaged in questionable business or marketing practices, including inducements or re‑characterizing services as other services once annual maximums have been reached
Remembert, even a single credible complaint can prompt an audit from an extended health insurer.
- Poor Recordkeeping Practices
Insurers have been known to initiate audits upon discovering that an RMT’s recordkeeping practices may be deficient. Examples include:
- Failing to consistently prepare clinical notes
- Missing patient histories, assessments or re‑assessments
- Utilization of templated chart notes rather than individualized notes
Inadequate records can also significantly undermine an RMT’s ability to defend their billings during an audit.
- Association With Previously Flagged Clinics
RMTs are at a substantially higher risk of audit if they are associated with a clinic that has a previous history of non-compliance with an insurer.
If inappropriate practices are occurring at a clinic, it can be exceptionally difficult for an RMT to convince an insurer that they were unaware of the conduct at issue. As such, RMTs should carefully vet their business associations, including by reviewing regulatory college public registers, the Financial Services Regulatory Authority (FSRA) website and lists of de-listed providers maintained by insurers.
- Prior Disciplinary History With CMTO
Increasingly, insurers are initiating audits solely because an RMT has a prior disciplinary finding with the CMTO related to billing matters.
In some cases, I have seen insurers delist RMTs solely on the basis of such disciplinary history, without even commencing a formal audit.
As such, I encourage RMTs to take every CMTO complaint/investigation very seriously and ensure that all potential steps are taken to avoid a referral to a discipline proceeding.
Final Thoughts
I hope this article has provided RMTs with practical, real-world insight into the most common triggers for insurance audits and how certain conduct can raise red flags.
By understanding how extended health insurers assess risk, RMTs can take proactive steps to adjust their practices and meaningfully reduce the likelihood of an audit.
About the Author
Lad Kucis is certified by the Law Society of Ontario as a specialist in health law and provides advice and representation to RMTs in respect of all types of regulatory matters, including complaints and investigations before the CMTO, and complaint reviews before the Health Professions Appeal and Review Board.
*Please note that this article has been prepared for information purposes only and is not intended to be construed as legal advice.