The publication in 2019 of the top 100 medical billings in Ontario for the years between 2011-2018 generated a lot of attention and scrutiny of the way medical professionals bill the Ontario Health Insurance Plan (OHIP). Also in 2019, the Ontario government announced plans to revise the Health Insurance Act with respect to the way billing works, including regularly publishing the billings. This is one of many health law changes proposed under Bill 138, which was introduced in November of last year. The stated reasons behind the proposal to publish medical billings are two-fold:

  1. To provide greater transparency to the public about the actual cost of medical services; and
  2. To ensure more stringent oversight and scrutiny of annual billings.

The Ontario Medical Association (the OMA) has a history of objecting to similar proposals to make medical billings public. The fear is that, without proper context, the billings may be misleading to those without the appropriate insight into the process. Without an understanding of clinic overhead, payroll and other expenses, members of the public may conclude that a physician’s billings are tantamount to income. Without the necessary understanding of how billings are distributed, the basic numbers do not paint an accurate picture.

With the passing of the Bill, the OMA has made it clear that it supports increased transparency with respect to OHIP billing, so long as the proper context is provided. How this will play out remains to be seen. Ontario will now become the fourth province in the country to make medical billings public information, following British Columbia, New Brunswick and Manitoba.

Changes to the Auditing Process

The government has also resolved to increase oversight into billing by adding more direct scrutiny through audits, inspections and reviews. The government has stated that the new auditing process will also have an increased education component for practitioners so that they can gain a better understanding of billing codes and processes.

Some are concerned that this new process may revert the system back to how it operated before an audit by former Supreme Court Justice Peter Cory in 2005. At the time, Justice Cory concluded that the existing system of oversight had a devastating effect on Ontario physicians, as they were faced with the prospect of defending against a presumption of guilt. After Justice Cory’s findings were released, the Physician Payment Review Board (PPRB) was established, changing the way billing review was carried out in the province.

The incoming changes will look to merge the PPRB with other audit agencies and boards, which is concerning for some. There is a worry that the system will revert back to the old model, putting medical practitioners back under intense scrutiny and facing an unfair, uphill battle when it comes to defending their billing practices.

An Increased Need for Experienced Health Law Counsel

With the incoming changes, it is clear that the increased oversight of billing practices will likely lead to a growing number of audits and disciplinary action. Retaining health law counsel to advise a practitioner of their rights and obligations, and to guide and represent them through the process will be key in order to protect their interests in a stressful situation. Our lawyers have considerable experience with the investigative and audit process and can explain your obligations and responsibilities, help protect your rights, and provide effective guidance and support throughout an investigation and beyond.

At Wise Health Law, we keep abreast of evolving developments in health care law and governance, and regularly blog about recent legal decisions affecting health care industries, health associations, and health professionals. If you have questions about changes to health care governance or about health law in general, contact our health law lawyers at 416-915-4234 or contact us online.

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