Ohip Bulletin and Govenment logo
Bulletin Number

4396

Date

January 16, 2003

Direct inquiries to

Ministry of Health and Long-Term Care Processing Office

(See Address Below)
Distribution

Physicians, Hospitals, Clinics and Laboratories


Subject

OHIP PAYMENT REVIEW PROGRAM

In November 1999, the Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Medical Association (OMA) initiated discussions on the Medical Review Committee (MRC) process. The 2000 MOHLTC and OMA agreement established a joint committee to review the MRC.

On November 9, 2001, the MOHLTC/OMA Joint Committee on the MRC provided its final report to the Physician Services Committee (PSC). It was agreed that the function of reviewing physician claims following referral by the General Manager of OHIP should remain with the MRC, but that a physician should be given the opportunity to attempt to reach an agreement with the ministry prior to a referral to the MRC. The PSC approved the report and forwarded it to the President of the OMA and the Minister of Health and Long-Term Care.

The OHIP Payment Review Program (OPRP) will implement this recommendation by providing physicians with the option to resolve a claims dispute through an agreement with the ministry prior to a referral to the MRC.

The OPRP will commence in January 2003. The program will be gradually phased in, and during the time required to fully implement the program, some referrals will continue to be made to the MRC. All referrals to the MRC made prior to the commencement of the OPRP will continue to proceed through the MRC process.

The OPRP will be transparent to all physicians. An identified physician will be provided with substantially the same information that the ministry would provide with a referral to the MRC. The OPRP will also employ a fact-based audit process, similar to that used by the MRC, including a review of a sample of patient service records.

Participation in the OPRP is completely voluntary on the part of the physician. A physician always has the option to end discussions with the ministry and proceed directly to the MRC.

Some of the advantages to a physician participating in the OPRP, rather than in an MRC review are :

Faster resolution of claim submission issues

  • Fewer people involved;
  • No additional charge for the cost of the review;
  • Interest starts after an agreement is reached, not at the end of the service period under review;
  • No publication of review information.