The Ernie Eves government is committed to ensuring that healthcare dollars are spent effectively and efficiently so that Ontarians can receive the best healthcare possible.

One of the largest portions of the ministry's $25.8-billion annual budget is the claims paid to healthcare providers under the Ontario Health Insurance Plan (OHIP). Each year, providers submit more than 130 million claims, equaling $4.5 billion in payments.

In the 2001-2002 fiscal year 23,000 physicians submitted claims to OHIP. About 2,500 physicians were reviewed by the ministry and, of those, only 100 were referred to the Medical Review Committee for a more detailed review. In 2001-2002, some $6 million of OHIP funds were recovered through this Committee.

The ministry has built a number of checks and balances into the OHIP system to ensure accountability to the people of Ontario.

A key part of the post-payment audit program is peer reviews performed by the five review committees (medical, chiropody, chiropractic, dentistry and optometry). These examine any billing irregularities that can't be resolved by ministry staff. Each committee is an independent body comprised of members nominated by the respective professional college and members of the public. For example, the Medical Review Committee (MRC), which is responsible for reviewing claims submitted by physicians, is comprised of 18 physicians nominated by the College of Physicians and Surgeons of Ontario and six members of the public.

A review committee examines the provider's charts and records as well as any other relevant information on how the provider has billed in the past. Following each review, a committee will direct the General Manager of OHIP to :

• pay the claims as submitted,
• pay the claims at a higher amount, or
• recover the claims paid to the provider.

Although the ministry cannot appeal a decision, a provider may appeal to the Health Services Appeal and Review Board, an independent tribunal.

A review committee will often direct a healthcare provider to repay money because the patient's service record doesn't match the fee codes billed to OHIP. Usually this is because there is insufficient documentation about the services performed for a patient, which means that payment by OHIP can't be justified. Poor record keeping also has implications for the quality of future care for patients.

If repayment is directed, ministry staff work with the provider to determine a repayment schedule. Payments can be made in a lump sum, although they are usually subtracted from future payments over the course of a year.

Some providers have expressed concerns about the other costs associated with a review. Providers are charged interest on the money owed and they must also pay a fee to cover part of the cost of the review. Interest charges are needed since the ministry is recovering funds already paid out to a provider and has a duty to Ontario taxpayers to manage the use of their funds in a responsible way. It's also important to note that any legal costs involved in appearing before the Medical Review Committee are usually paid by the Canadian Medical Protective Association, a medical insurance provider for physicians.

The ministry is always working to enhance accountability in the healthcare system and has actively collaborated with the Ontario Medical Association to build solutions that meet the needs of the government and healthcare providers. Some new initiatives include :

• educating physicians about correct and optimal billing practices (the Education and Prevention Committee - see below); and
• creating opportunities for physicians to discuss claims irregularities prior to the ministry taking corrective action (the OHIP Payment Review Program - see below).

This committee's objective is to provide physicians with information about how to submit claims correctly. By raising the level of physician awareness about the claims process and their responsibility for the claims they submit, the EPC removes barriers to accurate claims submission and reduces the need to recover payments for inappropriately submitted claims.

This new program, started in January 2003, is an alternative process to the Medical Review Committee that will require the ministry to notify a physician about an impending referral to the MRC. It will give the physician an opportunity to explain any apparent irregularity and will allow both parties to reach a mutually satisfactory agreement. If no resolution is reached, the referral to the MRC will proceed.