Bulletin

   
Bulletin Number
        2031
Date
        July 18, 2000
Direct inquiries to

         Ministry of Health
         Processing Office


(address below)
Distribution
       Independent Health Facilities
Subject      CHANGES TO MEDICAL REVIEW COMMITTEE PROCESS
This Bulletin describes a number of changes affecting the Medical Review Committee (MRC) process, including:

1. Where a physician requests an MRC review, the physician is entitled to a review by a single MRC member if the amount in dispute is less than $100,000.

2. Application fees apply when a physician requests a review or a reconsideration by the MRC.

3. Other measures include interest charges, an additional amount for cost, and the publication of names.

The Minister of Health and Long-Term Care is accountable for fees paid to health care providers for services insured under the Ontario Health Insurance Plan. Improper claims are identified and the money is recovered.

Improper claims are identified through:

    • pre-payment computer rejections
    • routine computer screening of all physicians' paid claims
    • ad hoc computer extracts/analysis
    • service verification letters to randomly selected patients
    • complaints from the public
    • reports from other program areas of the Ministry
    • detailed analyses of the claims of individual physicians.

Improper and fraudulent claims are controlled post-payment through:

    • referral for review by the MRC, with recovery of fees paid inappropriately
    • direct recovery by the General Manager of OHIP of fees paid inappropriately when MRC investigation not required (Note: a physician can request that the MRC review the General Manager’s refusal, reduction or recovery of payments)
    • referral to the Ministry’s Investigation Unit when criminal fraud is suspected.

Physicians who have questions about the appropriate claim for a given service should contact their regional OHIP office for clarification. It is in the best interest of the physician to seek that clarification, or at least have it confirmed, in writing. If the Monitoring and Control Section of the Ministry contacts a physician to discuss questionable claims, that also presents an opportunity to resolve any misunderstandings.

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Kingston, ON
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