Bulletin

Medical and Practitioner Review Committee Activity

As a result of legislative changes, enhanced information technology, and additional staffing, the ministry has improved its ability to detect and analyze claims that raise the suspicion of impropriety.  Physicians and practitioners are solely accountable for the propriety and accuracy of their claims to OHIP.

The General Manager of OHIP has four options for action available when it appears that incorrect claims have been submitted:

1. Letters to providers to point out unusual billing patterns

2. Direct recovery of funds under section 18 (5) of the Health Insurance Act (no review committee referral)

3. Referral to the appropriate medical/practitioner review committee for detailed review

4. If there is a suspicion of fraud, referral to the Investigation Unit, a team of OPP Anti-Rackets police officers dedicated to investigating health care fraud

Providers who have been directed to repay funds following a review committee review are also subject to:

• An interest charge on the amount of repayment, and

• A charge for the cost of the review.

Providers who have been directed to repay funds following a panel committee review may be subject to:

• Publication of the review committee case

The Health Insurance Act authorizes the General Manager of OHIP to publicize information about providers who have been directed by a panel of a Medical or Practitioner Review Committee to repay money received for improper claims.  This Bulletin contains the first release of this information.