Medical Review Committee Activity

This is the second Bulletin of a bi-annual publication on Directions issued by the Medical Review Committee (MRC). Bulletin #4383 published April 1, 2002, was the first release of information on such Directions.

Under the Health Insurance Act (HIA), the General Manager may refer claims that raise a concern about incorrect billing practices to the MRC. Usually this type of situation requires a detailed review of patient records that the MRC has the legal authority to undertake. A physician may also request that the MRC review a decision of the General Manager under the HIA to require repayment of improper claims.

The MRC is an independent committee administered by the College of Physicians and Surgeons of Ontario (CPSO). The MRC operates at arm’s length from both the CPSO and the ministry. The MRC consists of 18 physician members nominated by the CPSO and six members of the public. The Minister of Health and Long-Term Care appoints all members.

The MRC may perform either a panel review or a single-member review. Three physician members and one member of the public conduct panel reviews. Single-member reviews, or ”expedited reviews”, are conducted by one physician.

The MRC may direct that :

• the General Manager pay the claims as submitted or at a lesser amount, or
• the physician repay all or part of the claims.

MRC directions are binding on the General Manager. Physicians are the only parties who can appeal an MRC direction to the Health Services Review and Appeal Board (HSARB). HSARB directions can be appealed to Divisional Court.