Transitional Physician Payment Review Act, 2004, S.O. 2004, c. 13 - Bill 104
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chapter 13
An Act to amend the
Health Insurance Act and the
Ministry of Health Appeal and
Review Boards Act, 1998
Assented to June 24, 2004
Preamble
The people of Ontario and their Government:
Believe that accountability is the cornerstone of responsible use of public funds;
Recognize the skill, dedication and integrity demonstrated by the staff and the members of the Medical Review Committee in fulfilling the Committee’s vital role in medical audit within Medicare;
Acknowledge that timely payment of physician accounts is necessarily premised upon a Medicare payment system founded on trust;
Recognize that the Government in consultation with the College of Physicians and Surgeons of Ontario have retained Mr. Justice Peter Cory to conduct a “best practices” comparative analysis of medical audit systems and standards, to report back on any conclusions reached, and to make recommendations based upon those conclusions;
Recognize that, pending the outcome of that report, confidence in Ontario’s medical audit system may be enhanced by providing a transitional alternative audit process for physician accounts;
Affirm that the preservation of Medicare depends on collaboration between patients, health-care providers and Government;
Therefore, Her Majesty, by and with the advice and consent of the Legislative Assembly of the Province of Ontario, enacts as follows:
Part i
amendments to the
Health insurance act
1. The Health Insurance Act is amended by adding the following sections:
Physicians
18.0.1 (1) Subject to subsection (2), during the period that commences when this section comes into force, and ends when this section is repealed under section 18.0.4, sections 18.1 and 39.1 do not apply to a physician, and this section applies instead.
Saving
(2) Subsection (1) does not affect,
(a) a right to request a review by the Medical Eligibility Committee under clause 18.1 (1) (a); or
(b) any rights, responsibilities or obligations under subsections 18.1 (14) to (19) with regard to a review in which a final direction was given before this section came into force.
Panel Review
(3) Upon the request of a physician, the Transitional Physician Audit Panel is authorized to review the following matters in relation to that physician:
1. A decision of the General Manager to refuse to pay for a service, or to pay a reduced amount for a service under subsection 18 (2).
2. A decision of the General Manager to require reimbursement of an amount paid for a service under subsection 18 (5).
If review requested
(4) If a physician requests a review under subsection (3), the chair of the Appeal Board shall designate members of the Transitional Physician Audit Panel to deal with the review and set a time for the review and the panel shall conduct the review and render its direction as expeditiously as may be reasonably possible, and in any case shall render its direction no more than 45 days after the last day on which evidence in the review was adduced before the panel, unless the General Manager and the physician consent to an extension.
Parties
(5) Only the General Manager and the physician are parties to a review by the Transitional Physician Audit Panel.
Directions
(6) Following the review, the Transitional Physician Audit Panel may give any direction that could have been given by the Medical Review Committee under subsection 18.1 (10).
Interest, payable by physician
(7) If, as a result of a direction by the Transitional Physician Audit Panel, an amount is payable by a physician, interest calculated in the prescribed manner is payable on the amount, payable from the date the account was paid by the Plan.
Interest, payable to physician
(8) If, as a result of a direction by the Transitional Physician Audit Panel, an amount is payable by the General Manager, interest calculated in the prescribed manner is payable on the amount, payable from the date the amount was recovered from the physician by the Plan.
Applicability of certain provisions
(9) The following provisions apply, with necessary modifications, to a review by the Transitional Physician Audit Panel:
1. Subsections 21 (1.1) and (2).
2. Subsections 23 (1) to (4) and (6).
3. Section 27.2.
Appeal to Divisional Court
(10) Any party to a review before the Transitional Physician Audit Panel may appeal from the panel’s direction to the Divisional Court in accordance with the rules of court, but,
(a) personal health information contained in any document or evidence filed or adduced with regard to the appeal, or in any order or decision of the Court shall not be made accessible to the public; and
(b) the Divisional Court may edit any documents it releases to the public to remove any personal health information.
Transitional
Suspension
18.0.2 (1) Unless the physician elects otherwise under subsection (2), a review or reconsideration by the Medical Review Committee with regard to the physician is suspended for the period that this section is in force where, prior to its coming into force,
(a) the physician requested the review under subsection 18.1 (1) or the reconsideration of that review under subsection 18.1 (7); and
(b) the Medical Review Committee had not given a final direction from the review, or in the case of a reconsideration, a final direction from the reconsideration.
Election
(2) A physician may elect, instead of a suspension under subsection (1), to request a review by the Transitional Physician Audit Panel under section 18.0.1 as if he or she had never requested that the Medical Review Committee perform a review or a reconsideration of a review.
Suspension, section 39.1
(3) Unless the physician elects otherwise under subsection (4), a review or reconsideration by the Medical Review Committee with regard to the physician is suspended for the period that this section is in force where, prior to its coming into force,
(a) the General Manager had, in respect of the physician, requested the review under subsection 39.1 (1) or the physician had made a request for the reconsideration in accordance with subsection 39.1 (4); and
(b) the Medical Review Committee had not given a final direction from the review, or in the case of a reconsideration, a final direction from the reconsideration.
If no suspension
(4) If a physician is the subject of a request by the General Manager for a review under subsection 39.1 (1) or a request by the physician for a reconsideration in accordance with subsection 39.1 (4), the physician may elect that the General Manager, acting under subsection 18 (1), determine all issues relating to those accounts of the physician that formed the subject-matter of the request as if no request had ever been made.
Other issues if no suspension
(5) Where a physician elects under subsection (2) or (4) not to suspend a review or reconsideration, in respect of a review or reconsideration being conducted by the Medical Review Committee, no conclusion, decision or deliberation of the Medical Review Committee, whether of a preliminary, draft or final nature, is admissible in any subsequent review, proceeding or appeal, despite any other Act or law to the contrary.
Additional election
(6) Where, on the day this section came into force, a physician had received notice of a direction, and had not yet requested a reconsideration within the time provided under subsection 18.1 (8) or 39.1 (4),
(a) the physician may elect to request a reconsideration, and have it suspended under this section;
(b) the physician may elect a review under subsection (2) or (4), as the case may be; or
(c) the physician may elect to treat the direction as final, in which case any provisions of this Act that would have applied to the direction if it had become final before the coming into force of this section apply.
Rules re election
(7) An election under subsection (2), (4) or (6) must be made within 30 days from the day this section comes into force.
Notice
(8) Notice of election not to suspend under subsection (2) or (4) must be served on the General Manager.
Interest
(9) If a suspension applies under subsection (1) or (3) in respect of a request for a reconsideration, no interest is payable during the time that this section is in force on any amount payable by the physician as a result of the direction of the Medical Review Committee subject to the reconsideration.
Appeals
(10) In any appeal to the Appeal Board or the Divisional Court concerning a decision of the Medical Review Committee made before the coming into force of this section, the General Manager may elect to stand in the place of the Medical Review Committee, and if the General Manager so elects, he or she has all the rights and responsibilities of the Medical Review Committee for the purposes of the appeal.
Transitional
(11) Where on June 21, 2004 payments to a physician are suspended under subsection 40.2 (6), the suspension shall remain in effect until the physician has complied with subsections 37 (1) and (3) to the satisfaction of the General Manager.
Definition
18.0.3 In sections 18.0.1 and 18.0.2,
“Transitional Physician Audit Panel” means the Transitional Physician Audit Panel established under section 7.1 of the Ministry of Health Appeal and Review Boards Act, 1998.
Repeal
18.0.4 Sections 18.0.1, 18.0.2 and 18.0.3 are repealed on a day to be named by proclamation of the Lieutenant Governor.
Part ii
amendments to the Ministry of Health Appeal and Review Boards Act, 1998
2. The Ministry of Health Appeal and Review Boards Act, 1998 is amended by adding the following section:
Transitional Physician Audit Panel
7.1 (1) There is established a panel of the Board, to be known as the Transitional Physician Audit Panel in English and comité provisoire de vérification des honoraires de médecins in French, to deal with reviews under section 18.0.1 of the Health Insurance Act, consisting of,
(a) the members of the Board appointed under subsections (2) and (4); and
(b) the members of the Board who meet the qualifications set out in subsection (2) or (4).
Appointment, medical practitioners
(2) Despite subsection 7 (3), the Lieutenant Governor in Council, on the recommendation of the Minister of Health and Long-Term Care and in consultation with the Ontario Medical Association and the College of Physicians and Surgeons of Ontario, shall appoint no fewer than six legally qualified medical practitioners to the Board to serve as members of the Transitional Physician Audit Panel.
Restriction
(3) A legally qualified medical practitioner who was subject to a review by the Medical Review Committee or who was required to reimburse the Plan under the Health Insurance Act may not be appointed under subsection (2) until at least 10 years have passed since he or she was subject to a review by the Medical Review Committee or was required to reimburse the Plan.
Appointment, lawyers
(4) The Lieutenant Governor in Council, on the recommendation of the Minister of Health and Long-Term Care shall appoint to the Board no fewer than three members of the Law Society of Upper Canada, other than life members, honorary members or student members of the Society, to serve as members of the Transitional Physician Audit Panel.
Restriction
(5) Members appointed under subsections (2) and (4) shall not otherwise sit as members of the Board.
Rules re panel
(6) For the purposes of dealing with a review under section 18.0.1 of the Health Insurance Act, the following rules apply:
1. The review shall be dealt with by three members of the Transitional Physician Audit Panel designated by the chair of the Board.
2. Two of the three members shall be legally qualified medical practitioners, and one shall be a member of the Law Society of Upper Canada.
3. The chair of the Board shall designate a member to serve as chair for the purposes of the review.
4. The panel may not award costs.
5. Reviews by the panel are closed to the public.
6. Personal health information that is contained in any document or evidence filed or adduced with regard to the review, or in any order or decision of the panel, shall not be made accessible to the public, and the panel may edit any documents it releases to the public to remove any personal health information.
7. The parties to a review must exchange witness statements, summaries of evidence and copies of any documents proposed to be adduced in evidence at least 15 days before the day on which the review is scheduled to commence.
8. No evidence is admissible at a review that was not substantially disclosed in accordance with paragraph 7 and no document is admissible in a review that was not disclosed in accordance with paragraph 7.
9. The panel may not review, reconsider or amend a direction, decision or order except to correct a typographical error or error of calculation.
10. A review shall be conducted orally unless the General Manager appointed under the Health Insurance Act and the physician consent to the review being conducted electronically or in writing.
11. Subject to paragraphs 1 to 10, Part III applies.
Repeal
(7) This section is repealed on a day to be named by proclamation of the Lieutenant Governor.
Commencement
3. (1) Subject to subsection (2), this Act comes into force on the day it receives Royal Assent.
Same
(2) Sections 1 and 2 come into force on a day to be named by proclamation of the Lieutenant Governor.
Short title
4. The short title of this Act is the Transitional Physician Payment Review Act, 2004.