TEMPORARY SUSPENSION OF THE MEDICAL REVIEW COMMITTEE AUDIT PROCESS

The Transitional Physician Payment Review Act, 2004 is intended to temporarily suspend audits by the Medical Review Committee (MRC) while awaiting Justice Peter Cory’s recommendations for a best practices audit system. That review is expected to be completed by April 2005.

The new legislation also creates a panel of the Health Services Appeal and Review Board (HSARB) called the Transitional Physician Audit Panel (TPAP). This panel is intended to act as the temporary appeal body for any audit decisions made by the General Manager of OHIP.

During the temporary suspension, the Ministry of Health and Long-Term Care will continue to identify billing concerns which will be addressed through a new process (see process diagram).

Ministry of Health and Long-Term Care audit functions include:
Claims Records Review (‘Direct Recovery’)
When the General Manager can determine that claims to the Ontario Health Insurance Plan (“OHIP”) are incorrect based on a review of billing records, the General Manager may initiate a recovery of funds pursuant to the Health Insurance Act. If a physician disputes the General Manager’s decision, he or she may appeal to the TPAP within 15 days of notice of the decision.

Medical Records Review
When a review of the medical records is required, OHIP will notify the physician of the General Manager’s concerns. The physician then has two options: (1) he or she may choose to wait to be audited when the new audit process is available following Justice Cory’s recommendations for change, if any, or, (2) he or she may choose to undergo a ministry audit. If the physician then disputes the ministry’s decision, he or she may appeal the decision to the TPAP within 15 days of notice of the decision