Payment Integrity Ontario Health Insurance Program
Resource Manual for Physicians
3.3   Actions (Continued)

Records Review/Audit

As noted earlier, Payment Integrity may request records under certain circumstances. The authority to make this request is in the HIA or the CFMA (depending on the circumstance) and physicians have (for the CFMA, it is 21 days, for the HIA, it is within the time period the General Manger may require) to provide the records. Records are usually requested in order to ensure the proper claim was submitted for the service provided or to ensure that a fee has not been charged to a patient for an insured service.

Request for Reimbursement of Funds

Where Payment Integrity determines that an amount is owing to OHIP, the physician may be asked, in writing, to make a reimbursement. If the physician disagrees with the determination of an amount owing, there is an appeal process in place, details of which are given to the physician when notified of an amount owing.

Referral to an Independent Board

In situations where education has not been successful, and/or where a records review or audit has resulted in a disagreement between the ministry and the physician, the concern may be referred for consideration by an independent board. Physicians referred to the independent board will be notified and have the opportunity to make representations (either in person or through independent counsel) at the board.

Referral to the Fraud Branch

In situations where the concern is that the billing may be intentionally incorrect or inappropriate, Payment Integrity may refer the concern to the Fraud Programs Branch of the Ministry of Health and Long-Term Care. This branch reviews the concern and makes a determination on whether to forward to the Ontario Provincial Police (OPP) for possible criminal investigation.