Series of Reforms Aimed at Increasing Transparency in How Physicians Bill OHIP

Physician Billings Now Public

There has been longstanding public demand for increased transparency regarding the Ontario Health Insurance Plan (OHIP) and the manner in which healthcare professionals bill the province – and ultimately the public – for medically insured services. The Ontario government has recognized this demand, and has proposed a series of updates in response.

One such update proposed by the provincial government is the publication of physician OHIP billings. Making this information public will have a multifaceted impact on transparency. The government’s intention is not only to provide greater insight into the costs of medically insured services, but increased oversight and ultimately scrutiny over how much physicians bill the province each year.

The publication of physician-identified billings is the byproduct of an ultimately unsuccessful five-year long legal challenge involving physician-advocacy groups, including the Ontario Medical Association (OMA), who opposed disclosure of such information. In 2014, the Information and Privacy Commissioner of Ontario required disclosure of physician-identified billings, holding that they constituted business, rather than personal, information. The challenges by the physician-advocacy groups were ultimately unsuccessful, and culminated in April 2019 when the Supreme Court of Canada refused to hear their case. Each lower level of court had ruled that the transparency and openness expected of a government-run healthcare system required disclosure of billings. The Ontario Ministry of Health had previously stated that it would follow the ultimate court ruling, which is evident from the proposed reforms. The OMA had consistently maintained the position that any publication of physician payments should be a product of legislation, rather than a court ruling.

A central tenet of the OMA’s opposition to disclosure was the risk that publishing physician-identified OHIP payments, without further context, could potentially mislead the public. OHIP payments are not the equivalent of income; they do not account for overhead expenses such as staff salaries or equipment. The OMA was concerned that the public would conflate the two and assume that billings and income were one in the same, and would not appreciate that overhead expenses were paid for out of physician billings.

British Columbia, Manitoba, and New Brunswick currently make physicians’ billings public, and Ontario will soon follow suit. In response to these proposed changes, the OMA has welcomed the publication of physician billings, with OMA president Dr. Sohail Gandhi stating: “The OMA supports increased transparency and making physician billing information public as long as proper context is provided.” The government has stated it would work with the OMA in looking at billing disclosure going forward.

A Change to How Billings are Audited

Another incoming change aimed at increasing transparency in health care and the administration of OHIP is an update to the way in which physician billing practices are audited.

The reforms are said to increase the intensity of audits of physician’s billings, and will give the government greater authority to prevent, investigate and recover unauthorized payments to doctors. The province will administer audits through the use of inspectors, or reviewers, who may inspect anything he/she considers to be relevant to how a physician bills for their services.

The approach to auditing will focus not only on restitution and prevention, but education as well. The government backgrounder on the reforms stated “education on OHIP billing, to help providers understand how to bill and how to correct billings, will continue to be improved upon as an important support for physicians and other providers in reducing payment errors or misunderstandings.” The Ministry of Health stated that audits will be conducted with a focus on education because, as they have stated, it became clear from discussions with the OMA that there is a lack of knowledge in some areas about what appropriate billing codes are.

The auditing process was a focal point of a 2005 report by former Supreme Court of Canada Justice Peter Cory, who wrote that the previous auditing system administered under the now-defunct Medical Review Committee (MRC) had a “devastating” effect on physicians. Justice Cory found that the previous audit system was far too harsh on physicians, who faced an uphill battle of having to displace a burden of presumed guilt when facing examinations of their billing practices. The MRC system provided for a reliance on extrapolation, a notorious approach that applied the findings of a small sample set of physician billings to a physician’s greater practice. If a physician was found to have billed improperly in a sample of cases, it was assumed that the physician billed incorrectly in all cases. As a result of Justice Cory’s report, the Ontario Ministry of Health established the Physician Payment Review Board (PPRB), an independent adjudicative agency that oversees the administration of OHIP billings. As part of these upcoming reforms, the PPRB will merge with a number of other appeal boards and committees that deal with OHIP payments and coverage. There is concern that with the elimination of the PPRB, the auditing system will revert back to the old ways of the MRC, and with that a reliance on harsh, potentially unfair practices.

Although the OMA ostensibly shares a goal towards increased transparency, the support it has provided for the disclosure of physician billings has not extended to reforms related to the audit process. The OMA has cautioned against the proposed changes, with Dr. Gandhi stating “the proposed legislation treats every doctor in Ontario as being guilty until proven innocent.” However, William Kaplan, chair of the arbitration panel that had previously overseen a contractual dispute between the provincial government and the OMA, wrote in his report that the process for auditing and recovering unauthorized payments for medically unnecessary services needed to be modernized and streamlined.

It is clear that the provincial government, as well as the province’s physicians, share an interest in increasing transparency within the healthcare system, including by shedding light on appropriate billing practices. However, equally clear is the fact that these side diverge in terms of how exactly to make the system more transparent. Although the proposed reforms were made with an eye towards a more open and sustainable healthcare system, whether the changes will actually result in greater accountability remains to be seen.

If you have any questions about these changes please contact us.


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