Ontario doctors overcharge health insurance without being punished

The Ontario Ministry of Health and Long-Term Care is unable to adequately address fraud and improper payments claimed by physicians to the Ontario Health Insurance Plan (OHIP). Documents obtained by the CBC show that many bad bills are not followed up, and when the department requires reimbursement, it is powerless to recover the amounts owed to it.

Cases of potential fraud that are not tracked. Incorrect billings of $3 million, already identified, for which no refund request has been made. Sums being recovered that fall into oblivion.

As a whole, the fight against fraud and extra-billing in Ontario is able to recover barely 0.001% of the total budget of the RASO. Ontario doctors charge $12 billion a year to the government agency. “It’s less than a drop in the ocean, it’s pathetic” denounces the NDP spokesperson on health, France Gélinas.

The Ministry of Health and Long-Term Care recognizes that fraud and overbilling exists. However, he has no idea of ​​the exact size of the problem, not least because, since 2005, there have been no more inspectors going to the doctors’ offices to investigate.

The department does not have the capacity to see if there are any anomalies and is unable to adequately investigate to validate whether the information provided by the physicians is valid or not.

Gilles LeVasseur, Professor of Law, Management and Economics at the University of Ottawa

Auditor General denounces government laxity

In her 2016 report, the Auditor General denounced the Ontario government’s lax approach, which “is not actively working to recover overpayments through proactive reviews.”

“Not being an inspector has limited the ability of the department to recover undue payments,” she added.

The Ministry of Health and Long-Term Care says that a verification mechanism exists and that “the records of 200 to 300 physicians are reviewed randomly each year. That’s just 1% of the province’s 30,000 physicians.

Reimbursements difficult to obtain

According to documents obtained by Radio-Canada, the department obtained 48 voluntary refunds in two years. But we do not reveal how many requests for refunds have remained unanswered. The department, we are told, does not keep that kind of data. No follow-up is possible, says Gilles LeVasseur.

If there is no fear of being caught, “if there is no control mechanism and monitoring, believes the professor, it’s easier, it’s more tempting for a doctor to exaggerate his request reimbursement to health insurance. ”

It should not be believed that all doctors are fraudsters, argues France Gélinas. Sometimes extra-billing results from a bona fide error, for example by reversing two digits in a service code.

“Doctors are human beings,” she says, “they make mistakes. But when we discover them, we must make corrections. What the ministry does not do, at least not as much as it should.”

The government responds in rather vague terms.

Since last year, we have increased our capacity to increase the number of file reviews and actions have been taken to improve system accountability.

Helena Jaczek, Ontario Minister of Health and Long-Term Care
But neither the minister nor the department has elaborated on the concret

e measures that have been put in place.

The example of echocardiography

Even when discrepancies are discovered, the Ministry of Health and Long-Term Care has difficulty getting reimbursements. Not to mention that “the ministry is no longer following up with all physicians who have submitted inappropriate invoices in the past,” writes the Auditor General.

For example, in 2015-16, a pulmonologist who worked 361 days billed the province $ 1.3 million, almost five times the limit.

In 2016, $3.2 million was overpaid to physicians due to erroneous billing related to echocardiograms, which measures heart rate. The department has a detailed report in the hands. Two years later, nothing has been recovered.

It is unforgivable! We know which doctor billed too much, with the amount, the date and the name of the patient. But do not be fooled to go get the money? It insults me!

France Gélinas, NDP critic for Health

Fraud without follow-up

According to data obtained by the CBC from the Ministry of Health and Long-Term Care, six potential cases of fraud were reported to the police in 2016-2017. But the ministry did not follow up on whether charges had been laid, or whether doctors had been convicted. Impossible, therefore, to know if sums paid in excess could have been recovered.

Three other cases of questionable overbilling were submitted to an administrative tribunal, composed mostly of doctors, to decide whether the error was good or bad faith, and whether a refund was necessary. This tribunal has met five times since its creation. Each time, the doctor was whitened.

Professor Gilles LeVasseur calls for tighter control over extra-billing of doctors and increased accountability.

Too often, we keep these cases secret. They must be made public. When the public is made aware of the abuse, it passes messages to other [physicians], that your reputation and your credibility can be affected.

Gilles LeVasseur, Professor of Law, Management and Economics at the University of Ottawa
All of these flaws in the system mean that society in general is losing out, says Natalie Mehra of the Ontario Health Coalition.

Valuable dollars are allocated to people who should not receive them, and only a fraction of these funds are recovered. Imagine the millions that could be reinvested in care if surveillance was improved.

Natalie Mehra, Director of the Ontario Health Coalition

Health and Long-Term Care Minister Helena Jaczek says the province has a “robust” system to fight health insurance fraud and over-billing. But she adds that she “would like to be able to recover all this money, because it belongs to the taxpayers”.

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1 Comment

  1. When I was OHIP’s lawyer, the General Manager of OHIP referred physician payments to the Medical Review Committee (“MRC”) of the College of Physicians and Surgeons of Ontario. The MRC investigated physician payments. There were inspectors. Substantial monies were recovered. All that ended when a physician who was referred committed suicide.

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