Ontario failing to recover millions in fraudulent OHIP billings by doctors

Ontario's Ministry of Health is doing little to crack down on doctors who improperly bill OHIP, according to information obtained by CBC/Radio-Canada.

A freedom of information request shows the province has recovered only $1.1 million in illegitimate billings over the past two years, while the auditor general pointed in her 2016 report to some $6 million in fees improperly paid to doctors.

"This is a complete waste of taxpayers' money, taxpayers' money that was supposed to go to health," said NDP health critic France Gélinas in an interview with CBC News.

"It is incomprehensible that when the government sees those kinds of mistakes, that they don't recoup the money," Gélinas said.

This suggests little has changed since 2016, when Auditor General Bonnie Lysyk criticized the health ministry for inadequately investigating fraudulent billing and for failing to follow up on physicians with a record of charging inappropriate fees to OHIP.

"The ministry lacks effective enforcement mechanisms to recover inappropriate payments from physicians," Lysyk wrote in her 2016 report. "Unless a physician agrees to repay amounts voluntarily, it is very difficult to recover inappropriate payments."

The freedom of information request revealed that the ministry obtained 48 voluntary refunds (totalling $1.1 million) over the past two fiscal years. But the government did not reveal how many requests for refunds were made, nor the total dollar amount of fees inappropriately billed to OHIP.

Lysyk called for increased oversight of the fees that doctors charge OHIP, tougher enforcement of the rules and more effective recovery of the illegitimate payments.

"If there is no control mechanism and monitoring, it's easier, it's more tempting for a doctor to exaggerate a health insurance reimbursement request," said Gilles LeVasseur, a professor of law and management at the University of Ottawa, in an interview with Radio-Canada.

The freedom of information request shows that the ministry reported six potential cases of OHIP fraud to the police in 2016-17, but did not follow up on whether charges had been laid or whether doctors had been convicted.

Ministry officials say the billing records of 200 to 300 physicians are randomly selected for review each year. There are about 30,000 doctors in Ontario.

The government also relies on information from patients. However, only a handful of patients respond.

The freedom of information request revealed that the ministry sent more than 458,000 letters to patients over the past two years asking to verify that their physician performed the services that were billed to OHIP. Fewer than 9,000 patients replied, a response rate of less than two per cent.

"We certainly have a very robust mechanism and process to look at potential OHIP overbilling," insisted Health Minister Helena Jaczek in an interview with CBC News. "Obviously this is taxpayers' money. I know our government really cares that we make sure every dollar is used to every extent possible in appropriate ways."

The government says it accepts the auditor's recommendations on the issue and is working to put them into practice.

"Since the release of the recommendations, the ministry has increased capacity in an effort to enhance volume of ongoing payment accountability review cases," said Jaczek's press secretary Laura Gallant in an email to CBC.