Ontario overhauls medical audit regime

Ontario's medical audit system will become less onerous this fall as a result of recent provincial legislation that limits the worst abuses of its widely criticized predecessor, the Ontario Medical Association (OMA) says.

The new system addresses many of previous system's shortcomings by providing “transparency and fairness,” says OMA President, Dr. Janice Willett. “It will also provide accountability on physician billing.”

“The legislation is … a big improvement,” she added.

Bill 171 (the Health System Improvements Act, 2006), which was passed in June, establishes the Physician Payment Review Board, charged with determining whether a physician's billings to the Ontario Health Insurance Plan (OHIP) for medical services have been appropriate, and/or whether a physician must make repayment for claims that were false. Each year, Ontario's 24 000 physicians bill OHIP $5 billion, about 100 doctors are audited and $5 million in payments is recovered.

The new regime replaces one formerly run by the Medical Review Committee of the College of Physicians and Surgeons of Ontario, which was pilloried by former Supreme Court Justice Peter Cory in an April 2005 report. Cory found that audits took too long to complete, the methods of assessment and collection were unfair and the hearing process left doctors feeling they were presumed guilty from the start.

Cory wrote that “The medical audit system in Ontario has had a debilitating and, in some cases devastating … effect” on physicians.

Cory recommended adopting most of the reforms suggested by the OMA, including establishing an independent physician audit board.

Willett says the new system incorporates many of Cory's recommendations. the OMA plans to continue working with government to set up the committees.

The new Physician Payment Review Board will comprised between 26 and 40 members, at least 20 of whom must be practising physicians. Panels of 4 (including 3 physicians) will handle individual cases.

If the agency decides the medical services weren't provided, weren't medically necessary, were unprofessionally delivered or were misrepresented, the physician will be notified and have the option of either accepting or challenging OHIP's decision before an independent panel. The recorded hearings must be held in accordance with procedural standards, and findings can be appealed to the Divisional Court of Ontario.

The board will have to power to suspend a doctor's right to bill OHIP and must report all findings of misconduct to the college. Among other changes are a new method for calculating interest awards, a provision that allows doctors to recover legal costs and limitations on the authority of auditors to “extrapolate” and order reimbursement for a large number of claims based on the review of just a few.