Recently I’ve been following the story of Dr. Alfred Nkut, a Sudbury area family physician currently on trial for defrauding the Ministry of Health and Long-Term Care of an alleged $800,000 in OHIP over-billings.   Despite billing OHIP claims as early as 2003, the volume and dollar amounts of Dr. Nkut’s billing changed dramatically in 2007.  In fact, in 2008 and 2009, he was the top-ranked non-psychiatrist billing time-based counselling codes in the province.

What was Dr. Nkut doing to raise OHIP’s suspicions?  Instead of billing more appropriate -and less lucrative – assessment codes for his patient visits, Dr. Nkut began to bill time based counselling codes in their place.   Most counselling codes have minimum time requirements of 20 minutes before a physician can bill one unit, and these codes are compensated at a much higher rate than typical GP assessment codes.  For instance, the fee for an intermediate GP assessment (A007) is currently $33.70, whereas the fee for one unit of Primary Mental Health Care (K005) is almost double that at $62.75.   According to the Sudbury Star, there were days when Dr. Nkut saw 90-120 patients over his 9 hour day meaning he would have spent, at most, 6 minutes per patient, and this is certainly not long enough to justify billing time-based K-codes.

Whether Dr. Nkut knew he was billing incorrectly with the intent of defrauding the OHIP system is the key question of the trial, and not one I care to speculate on.  But there are several other issues at play here that all physicians should consider, and the next couple of blog posts will explore these issues in detail.  First, what is the process of an OHIP audit? How do they start? What can the physician expect? Second, assuming Dr. Nkut had no intention of defrauding the system and that he really felt he was billing properly, what could he have done to prevent this horrible situation from occurring?  What should all physicians learn from the story of Dr. Nkut?

For more information about Dr. Nkut’s trial, see the almost daily articles by Harold Carmichael in the Sudbury Star beginning in mid September.