DETAILS OF RECENT CHANGES TO THE REVIEW COMMITTEE PROCESS
1. Practitioner Requests a Review by the Review Committee
A practitioner is notified of an adjustment to payment of claims by the General Manager through either a claim item adjustment (with notice in the Remittance Advice) or an accounting transaction (with notice by letter). Within 60 days of being notified of an adjustment, a practitioner may request a committee review.
A practitioner may request that the review be a single-member review if the amount in dispute is less than $100,000. If the amount exceeds $100,000 a practitioner may request that the General Manager exercise his or her authority to consent to a single-member review.
If a practitioner disagrees with the decision of a single committee member, he or she may, within 15 days of receiving notice, request that a full panel of the review committee reconsider the matter.
2. Application Fees for Practitioner-Requested Reviews
A request for a committee review must include the appropriate application fee. The application fee for a review is 10% of the amount in dispute but not more than $5,000; for a reconsideration, $750. If the review committee finds there have been no inappropriate claims, the application fee is returned to the practitioner. In other cases, the situation is as follows: if the application fee exceeds the costs of the review or reconsideration, the difference is refunded; if the costs exceed the application fee, the practitioner pays the difference.
3. Consequences of a Review (Practitioner-Requested or OHIP-Requested)
If the review committee finds there is an amount owing by or to a practitioner, interest is added to the amount owing.
For example, using an interest rate of 5% and assuming a review were completed two years after the end of the period being reviewed, the interest charge for a recovery amount of $30,000, up to the time of the committee’s direction, would be $3,000.
If the review committee finds there have been improper claims, the practitioner is required to pay an additional amount toward the costs of the review or reconsideration. The amount is determined from a formula based upon the duration of the review.
For example, assuming a typical review by a full panel of the review committee and a repayment of $30,000, the estimated additional amount for cost could exceed $10,000. It is anticipated that the time required for a single-member review would be significantly reduced, as would the associated cost. As well, a settlement offer from the practitioner can reduce the duration of the review and lead to a lower cost amount. Regardless of the duration of the review, the cost amount cannot exceed 0.35 times the recovery amount.
In addition to the above regulatory changes, the Savings and Restructuring Act, 1996 provided for the publication of information about review committee activity. Information including the practitioner’s name and the circumstances may be made public following a reconsideration or a panel review. (However, information cannot be made public following a single member review for which there is no reconsideration.)
|Ontario Ministry of Health and Long-Term Care
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