Given the volume of OHIP billing that JCL has processed for hundreds of physicians over the years, we have had very little occasion to deal with serious payment integrity issues. That said, once or twice a year our doctors do receive letters from the Ministry of Health requesting further information about their medical billing. The following provides a good example of the OHIP Payment Integrity program in action.
In May 2013, one of our internists received a request to submit documentation and an explanation regarding four in-patients for whom she billed two visits on the same service date. This physician’s claims assessor noticed the claims and felt they were unusual enough to merit review at a higher level. Our physician provided her notes and an explanation about why multiple visits were necessary. After reviewing the documentation, the MOH provided a very detailed explanation of the situations where multiple visits to the same in-patient on the same day were warranted. They also determined that our doctor’s records did not support multiple visits for the four patients in question, and rejected the second visits. We reviewed the decision with our doctor and were satisfied by the feedback. The payment review process was successful in its primary goal: To educate and inform physicians about appropriate medical billing habits and protocols.
Claims Assessors
One element of this story worth noting is the mechanism that started off the review process in the first place: a claims assessor noticed something unusual and escalated the concern. Each doctor in Ontario is assigned to a claims assessor at his or her district office. This claims assessor is responsible for processing the physician’s claims and dealing with any payment issues that arise. In communicating with dozens of claims assessors across district offices over the years, we at JCL are always amazed by the differences in their interpretations of the Schedule of Benefits, and what they consider “appropriate” medical billing. In the case study above, for instance, our doctor happened to have a claims assessor who felt her billing pattern was worth exploring. If our doctor had a different claims assessor, she may not have been asked for her records and the claims would have been paid as billed.
This variability can be a point of frustration for physicians who may have colleagues getting claims paid under similar circumstances, and it can lead to inconsistent billing patterns and confusion about interpretation. But this variability, while not ideal, is also not surprising – it simply reflects the nature of the Schedule of Benefits in all its shades of gray.