On-site collection of records and information

In rare circumstances, the Ministry of Health (MOH) may exercise its statutory authority under the Health Insurance Act (HIA) to collect records and other information at a physician’s office through use of an on-site reviewer (OSR). The OSR is always a physician who has received appropriate training. Although the use of on-site reviews is exceptional, they can be necessary when, for example, a physician refuses to provide records following multiple requests, or in the unlikely event there is evidence of records alteration. The records and information collected through an on-site review are used to continue the audit process.

The following explains the process the MOH will use when utilizing OSRs during post-payment audits of OHIP billings. OSRs are physicians and are only used to collect records and information in the rare situations as outlined below, to ensure compliance with the Health Insurance Act and its regulations.

The on-site review process focuses on the principles of accountability, fairness and transparency, as well as respect for physicians. Physicians are able to retain counsel at any point in the audit process, and are encouraged to contact the CMPA for assistance. Physicians are required to give all reasonable assistance to the reviewer in the exercise of his/her powers and performance of duties. The reviewer must keep all information confidential and shall not communicate any information except to the general manager and staff, or as required by law.

When does the MOH engage OSRs?

It is the MOH’s experience that the majority of physicians provide records when requested and the use of OSRs is therefore not necessary in the vast majority of circumstances.

Under rare circumstances, the MOH may collect records and other information through the use of an OSR, such as:

• no response from the physician or their legal representative after records are requested in writing, at least twice
• evidence or reasonable grounds for the MOH to suspect that records were modified by the physician before being submitted to OHIP for audit
• refusal to provide relevant records to support billings
• failure to respond to requests for clarification and/or additional information

How does the MOH engage and deploy OSRs?

The MOH will schedule an on-site review with the physician at an agreed-upon time and within a reasonable time frame. If the parties are unable to agree on a time, the MOH may designate a time within regular business hours and provide written notice at least one week in advance to the physician.

In exceptional circumstances, OSRs may perform unannounced visits where:

• there is evidence or reasonable grounds to suspect that records were modified by the physician before being submitted to OHIP as part of the audit
• the physician has not agreed to a time for a scheduled visit

The on-site review will take place at the location where the records and/or information in question are maintained. Physicians will be provided with a copy of this document at the time of written notice or on arrival at the time of an unannounced visit.

OSRs are physicians appointed by the minister or general manager of OHIP and will only collect records and information relevant to the substantial billing concern(s) which form the subject of the audit. The OSR may:

• examine records or things such as schedules or day sheets
• take copies of records
• require the production of a record or any other thing such as schedules or day sheets
• question a person about a matter relevant to the inspection
• call upon experts to provide assistance to the reviewer. For example, the OSR may attend the premises of the physician with a clinical expert or IT expert to assist in the collection of electronic information

The OSR will use electronic methods of copying whenever possible. Photocopying, if required, will be done on-site whenever possible. If this is not practical, the OSR will, upon providing a receipt, remove the records for review, examination and copying. Records removed shall be returned within a reasonable time and shall not exceed 15 days.

What happens after the collection of records?

The OSR will notify the physician once they have completed the collection of records and the ministry Provider Audit Unit will communicate next steps. The claims review/audit will then continue as per the process set out in the physician fee-for-service post-payment audit process and process diagram (PDF).