Stages of the post-payment audit

Claims for payments are to be submitted to the Ministry of Health in accordance with the Health Insurance Act, Regulation 552, and the Schedule of Benefits payment requirements. The ministry’s Provider Audit Unit conducts reviews of claims where a potential billing concern arises. A potential billing concern means that payment requirements may not have been met for the claim(s) submitted. Some examples include billing for services that were apparently not rendered, billing for a more complex service when a lesser service appears to have been performed, and billing multiple codes for a service that appears to be described by one fee code. The Provider Audit Unit is staffed with trained individuals who specialize in reviewing OHIP billing claims. The Provider Audit Unit has access to medical consultants who may assist in the review of OHIP claims, and the unit has quality assurance processes to enhance the quality of post-payment audits.

Post-payment audits of physician billings will be conducted in accordance with the following process: initial action, full review and board hearing.

Physician Post-Payment Audit Review Process diagram (PDF)

Initial action

Identifying potential billing concerns

Potential billing concerns come to the ministry’s attention in a number of ways. Currently, the majority of billing concerns are identified through tips or complaints received from the public, employees in the health-care system, or other physicians. The ministry may also become aware of billing concerns through other government program-area reviews as well as other organizations and regulatory bodies (such as the College of Physicians and Surgeons of Ontario). Examples of other government program-area reviews that could lead to a referral include the Commitment to the Future of Medicare Act Program (identifying a potential OHIP billing concern while performing an investigation related to extra billing), or a ministry program area noting, through the course of their work, changes in historical billing behaviour or volumes (such as the utilization of a new fee schedule code).

To report suspected cases of abuse, both health-care providers and members of the public may call 1-888-781-5556 or e-mail the ministry. Reports can be made anonymously.

No determination with respect to the billings submitted by physicians have been made by the ministry at this stage in the process.

Preliminary review/claims data review

When a potential billing concern is identified, the Provider Audit Unit conducts an impartial review of the physician’s claims history data from the ministry’s claims payment system to obtain more information about the concern and understand the physician’s practice and whether there is merit to the billing concern.

Based on the findings of the preliminary review of a potential billing concern, the ministry may choose to:

• take no further action if no billing concern is identified
• contact the physician to provide billing education to improve claim submission accuracy
• request that the physician review their own records and correct a payment error if, in the physician’s own assessment, a payment error has occurred
• proceed to a full audit if a potentially substantial billing concern is identified; there has been no determination by the ministry with respect to the billings submitted at this point

As each review is guided by its own facts, the determination that a potentially substantial billing concern exists may vary depending on the circumstances.

Full audit review

Request for records and information

If a potentially substantial billing concern is identified during the initial action stage, the ministry will contact the physician in writing to inform them of the existence of the review, provide information about the audit process (including a link to this description of the audit process), and request medical records and other practice information that the physician may have in their possession to support the review. Initial correspondence during this stage will clearly explain the ministry is collecting information about a potential billing concern and that nothing has been decided. This is also one of many opportunities in the process for the physician to provide any information to the ministry that the physician believes the ministry should know in conducting a review of their claims for payment. The information provided by the physician will help the ministry to better understand the services provided and determine the appropriateness of the fee schedule code(s) claimed.

The ministry requests a response from the physician within two weeks to confirm that the requested information will be provided to the ministry, and if the timeline for submission of the request is achievable. Reasonable requests for an extension will be approved. Refusal to provide records may have serious consequences, including the suspension of payments and/or court action, where a judge or justice of the peace may order the physician to provide the records.

In rare circumstances, the ministry may collect records and other information at a physician’s office through the use of an on-site reviewer. The on-site reviewer is a physician who has received 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. The records and information collected through an on-site review are used to continue the audit process.

The request for records and information process is typically completed within three to six months, dependent on the scope of the records request and the timeliness of response by the physician.

Records review and findings

Medical records and other relevant information provided by the physician are reviewed by the Provider Audit Unit to confirm that the fee schedule code(s) billed were appropriate based on the payment requirements in the HIA, Regulation 552, the Schedule of Benefits and, as demonstrated in the medical record, that a medically necessary OHIP-insured service was provided. The ministry may seek assistance of external medical experts as part of the process. Once the initial review findings are prepared, the ministry informs the physician in writing and the physician is given an opportunity to provide a written response to the ministry’s findings. In addition to the review findings, the physician’s submission may assist the ministry further in gaining a better understanding of the physician’s billings to OHIP.

The ministry is committed to ensuring all payment requirements are applied consistently.

The records review and findings process is typically completed within three to six months from the date records and other relevant information are received from the physician.

OHIP general manager’s opinion

The general manager’s opinion will describe the outcome of the ministry’s audit. The opinion is formed based on information provided by the Provider Audit Unit, including the ministry’s claims data and medical records review, as well as all information provided by the physician to the ministry. The ministry will notify the physician of the general manager’s opinion in writing.

If the ministry is satisfied with the physician’s explanation of billing practice and concludes that the claims reviewed were appropriate for the service(s) rendered, the ministry will notify the physician and take no further action. Conversely, if the ministry concludes that inappropriate claims were submitted, the ministry may choose to:

• contact the physician to provide billing education to improve claim submission accuracy and advise the physician that further review of claims may occur
• seek to resolve the audit outcome through a settlement with the physician
• refer the matter to the Health Services Appeal and Review Board (HSARB) for a hearing

Formation of the general manager’s opinion and notification to the physician is typically completed within one to three months following the records review and findings process.

The ministry endeavours to complete audits as quickly and efficiently as possible, while providing clear, accurate and timely information to physicians. Generally, the entire audit process takes less than 12 months to complete. Note that case-specific factors can extend the time needed for any part of the review process. The ministry will be in communication with the physician throughout the process.

Board hearing

If the general manager (GM) is of the opinion that a circumstance in subsection 18(6) of the HIA exists with respect to payments made to a physician, the GM may refer the matter to the Health Services Appeal and Review Board (HSARB) for a hearing. The HSARB is an independent quasi-judicial adjudicative tribunal with jurisdiction to decide billing audit disputes between the GM and physicians. A review panel will be three members, consisting of one physician and two non-physicians (one of whom must be a lawyer).

HSARB replaced the old Physician Payment Review Board and its processes.

The physician will be notified of matters referred to the HSARB and will have the opportunity to make representations. The board will conduct a hearing and make an order pursuant to the process set out in Schedule 1 of the HIA, and the board’s rules of procedure. Audit information may become public through the HSARB process.

Absent a settlement agreement or voluntary repayment, the ministry can only recover funds if repayment is ordered by the HSARB.

The HSARB can only order repayment for a period that is no more than 24 months in duration and that commenced no more than five years before the GM’s request for a review.

If either party is unsatisfied with the board’s order, that party may appeal the board’s decision to the Ontario Superior Court of Justice – Divisional Court. Learn more about the Health Services Appeal and Review Board.

Referrals

At any point in the process, the ministry may also refer matters to other bodies as appropriate, including:

• the College of Physicians and Surgeons of Ontario (CPSO) for investigation; where the Minister or General Manager is of the opinion that it is advisable to do so for the proper administration of the Regulated Health Professions Act, 1991 or an Act named in Schedule 1 to that Act, the Minister or General Manager is required to disclose information to a College. This would include circumstances, for example, where professional misconduct or patient safety concerns are suspected
• other ministry program areas if impacted by the concern identified through the ministry’s audit (such as Digital Health)
• the Ontario Provincial Police (OPP) Health Fraud Investigation Unit for investigation if fraud is suspected