Optometrists 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. Optometrists, like all other Health Insurance Act 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 Optometry Review Committee for detailed review.
4. If there is a suspicion of fraud, referral to the Investigation Unit, a team of OPP police officers dedicated to investigating health care fraud.

The Optometry Review Committee (ORC) is an independent committee administered by the College of Optometrists of Ontario. The ORC operates at arm’s length from both the College of Optometrists of Ontario and the ministry. The ORC consists of three practitioner members nominated by the College of Optometrists of Ontario and two members of the public. The Minister of Health and Long-Term Care appoints all members.

The ORC may perform either a panel review or a single-member review. A panel review consists of two practitioner members and one member of the public. Single-member reviews, or “expedited reviews”, are conducted by one practitioner.

The ORC may direct that :

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