Bulletin

   
Bulletin Number
        7073
Date
        August 3, 2000
Direct inquiries to

         Ministry of Health
         Processing Office


(address below)
Distribution
       Podiatrists

NOTE: THIS BULLETIN REPLACES BULLETIN #5065 – JULY 18

Subject      CHANGES TO MEDICAL REVIEW COMMITTEE PROCESS

This Bulletin describes a number of changes affecting the Review Committee process, including:

  1. Where a practitioner requests a review, the practitioner is entitled to a review by a single member if the amount in dispute is less than $100,000.
  2. Application fees apply when a practitioner requests a review or a reconsideration by the review committee.
  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 practitioners' 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 practitioners.

Improper and fraudulent claims are controlled post-payment through:

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

Practitioners 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 practitioner to seek that clarification, or at least have it confirmed, in writing. If the Monitoring and Control Section of the Ministry contacts a practitioner to discuss questionable claims, that also presents an opportunity to resolve any misunderstandings.

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