Payment Integrity Ontario Health Insurance Program
Resource Manual for Physicians
3.2  Processes (Continued)

Calls or Complaints

When a call or complain is received, Payment Integrity reviews the information and may conduct additional analysis based on the call or complaint. If there are concerns, Payment Integrity may request records or send written correspondence to the physician to clarify the matter of concern. Calls or complaints may also result in investigations under the CFMA. Physicians should be aware of their responsibilities under the CFMA to know what services are insured.

Verification Letters

The Verification Letter Program sends randomly generated letters to individual patients on a monthly basis. These letters are used to confirm that specified insured health services were received from a specified physician on a specified date. If the patient did not receive the service, or is unsure, the patient returns the letter to the ministry. Payment Integrity may then follow-up with the physician. Random verification letters are generated from all claims that are submitted to OHIP and do not specifically target a physician or patient.

3.3   Actions

Actions which may result from the processes of Payment Integrity include :

  • Education
  • Records review/audit
  • Request for Reimbursement of Funds
  • Referral to an Independent Board
  • Referral to the Fraud Branch

One of the functions of the Payment Integrity unit is to educate and assist physicians in correctly billing OHIP for services provided. In addition to correspondence addressed to individual physicians for very specific billing matters, the unit also addresses larger groups of physicians through its Provider Education Program (PEP). The PEP, initiated in 2001, was designed to improve physician awareness and understanding of payment requirements for a specific fee code or codes. PEP ‘studies’ are conducted on specific fee codes (or fee code combinations) and physicians meeting certain criteria may receive a letter clarifying the payment requirements.