Payment Integrity Ontario Health Insurance Program
Resource Manual for Physicians

3.1   Overview

The Ministry of Health and Long-Term Care is committed to ensuring that physicians who provide insured services to insured persons in Ontario receive full payment, within the requirements of the Health Insurance Act (HIA) and its regulations (including the Schedule of Benefits for Physician Services).

The ministry is accountable for fees paid to physicians for services insured under the Ontario Health Insurance Plan (OHIP). In support of that mandate, the Payment Integrity unit of the Provider Services Branch is responsible for reviewing the fee-for-service claims of physicians and responding to other payment concerns.

The authority under which the unit may act is outlined in the Health Insurance Act (HIA), the Commitment to the Future of Medicare Act (CFMA) and their respective regulations.

3.2   Processes

Payment integrity uses computer query tools and other computer software to conduct routine analysis on OHIP fee-for-service claims. In specific situations, Payment Integrity may be required to conduct further analysis of claims as a result of a call or complaint from a patient, another health care provider or some other source. Another prompt for further analysis may be the return, from a patient, of an adverse verification letter.

Computer Tools

Software is used to review post-payment claims. In general, most claims are paid as submitted, however; there are some computer checks performed on claims prior to payment. These checks are relatively general in nature (e.g., valid health number, maximum billing of a claim on one day) and cannot validate that the claim submitted is correct or appropriate for the service provided. Therefore, post-payment review through the use of software is required to identify other situations which may be of concern.