At the beginning of the 21st century, the government of a western Canadian province started holding physicians accountable for their overall billing patterns, with the annual reporting of each physician’s practice profile. This allowed physicians to compare their practice patterns with others, but it also provided the government with a guide to detect outliers suspected of fraud and abuse. In addition, it raised the need to use risk adjustment tools to ensure that physicians were being evaluated fairly.
Prior to the introduction of the ACG® System, audit results showed that, in 3 out of 4 cases, high healthcare expenses were justified by a sicker patient pool. After the ACG System was extensively evaluated in this particular Canadian province, it became accepted as the gold standard case mix adjustment method for physician profiling. Subsequent audit results then showed that unjustified healthcare expenses were actually confirmed in 3 out of 4 cases identified.
The ACG System continues to be successfully used for physician profiling and the detection of fraud and abuse in this province. The ACG System has been widely adopted in Canada with more than 60 projects currently being conducted across the country.
