O. Reg. 149/00: GENERAL

 

ONTARIO REGULATION 149/00

made under the

Health Insurance Act

Made: March 1, 2000
Filed: March 3, 2000

Amending Reg. 552 of R.R.O. 1990

(General)

Note: Since the end of 1998, Regulation 552 has been amended by Ontario Regulations 58/99, 59/99, 60/99, 85/99, 108/99, 177/99, 178/99, 201/99, 232/99, 271/99, 334/99, 368/99, 482/99, 483/99, 490/99 and 67/00.  Previous amendments are listed in the Table of Regulations in the Statutes of Ontario, 1998.

1. Subsection 38.2.1 (1) of Regulation 552 of the Revised Regulations of Ontario, 1990 is amended by striking out “on a simple interest basis” in the fourth line.

2. Sections 38.2.2 and 38.2.3 of the Regulation are revoked and the following substituted:

38.2.2 (1) For the purposes of subsection 18.1 (15) of the Act, if, as a result of a review or a reconsideration of a review under section 18.1 of the Act, a physician or practitioner is required to reimburse money to the Plan or a direction is made directing the General Manager to pay an amount to a physician or practitioner that is less than the amount of the account submitted, the additional amount for the cost of the review or for the cost of the reconsideration of the review shall be calculated using the following formula:

where,

A  is,

(a) where the physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, or

(b) where the General Manager is required to pay less than the amount of the account submitted, the portion of the amount the physician or practitioner claimed, in the review or reconsideration, should be paid to him or her that has been refused by the review committee;

B  is,

(a) where the physician or practitioner is required to reimburse money to the Plan, the amount that the physician or practitioner claimed he or she should not be required to reimburse in the review or reconsideration, or

(b) where the General Manager is required to pay less than the amount of the account submitted, the amount that the physician or practitioner claimed should be paid to him or her in the review or reconsideration;

C  is $1000, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500, in the case of a review or reconsideration conducted by a practitioner review committee;

D  is the number of review days in the review or reconsideration, as determined under subsection (5).

(2) Despite subsection (1), the additional amount determined under that subsection shall not exceed the lesser of,

(a) the amount that is,

(i) where the physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, multiplied by 0.35, or

(ii) where the General Manager is required to pay less than the amount of the account submitted, the portion of the amount the physician or practitioner claimed, in the review or reconsideration, should be paid to him or her that has been refused by the review committee, multiplied by 0.35; and

(b) $1000 for each review day, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500 for each review day, in the case of a review or a reconsideration conducted by a practitioner review committee.

(3) For the purposes of subsection 18.1 (15) of the Act, if, as a result of a review or a reconsideration of a review under section 18.1 of the Act, a direction is made confirming the decision of the General Manager to refuse to pay an account for services or if, as a result of a review or a reconsideration of a review under section 39.1 of the Act, a physician or practitioner is required to reimburse money to the Plan, the additional amount for the cost of the review or for the cost of the reconsideration of the review shall be calculated using the following formula:

C × D

where,

C  is $1000, in the case of a review or reconsideration conducted by the Medical Review Committee, or $500, in the case of a review or reconsideration conducted by a practitioner review committee;

D  is the number of review days in the review or reconsideration, as determined under subsection (5).

(4) Despite subsection (3), the additional amount determined under that subsection shall not exceed,

(a) where a direction is made confirming the decision of the General Manager to refuse to pay an account for services, the amount that the physician or practitioner claimed should be paid to him or her in the review or reconsideration, multiplied by 0.35; or

(b) where a physician or practitioner is required to reimburse money to the Plan, the amount that is required to be reimbursed, multiplied by 0.35.

(5) For the purposes of subsections (1), (2) and (3), the number of review days in a review or reconsideration shall be determined as follows:

1. For each member of the committee, determine the number of days, including any partial days rounded to the first decimal, the member spent working on the review or reconsideration and on matters related thereto.

2. If the parties agreed to a settlement of the review or reconsideration, determine, for each member, the number of days, including any partial days rounded to the first decimal, the member spent considering and agreeing to the offer to settle.

3. For each member, subtract the number of days determined for the member under paragraph 2 from the number of days determined for the member under paragraph 1.

4. Add the numbers determined under paragraph 3 for each member to calculate the total number of days all the members of the committee spent working on the review or reconsideration and on matters related thereto.

(6) Despite subsections (1) and (3), the additional amount for the cost of a review or for the cost of a reconsideration of a review shall be a nil amount if the physician or practitioner who is a party to the review or reconsideration made an offer to settle the matter and the offer was refused and,

(a) where the issue in the review or reconsideration related to whether the Plan owed money to the physician or practitioner, the settlement offer provided that the physician or practitioner accept payment of an amount that was equal to or less than the amount that the committee or single member directed that the Plan pay; or

(b) where the issue in the review or reconsideration related to whether the physician or practitioner owed money to the Plan, the settlement offer provided that the physician or practitioner reimburse an amount that was equal to or greater than the amount that the committee or single member directed the member to reimburse.

(7) Upon the recommendation of the review committee, the General Manager may reduce the additional amount payable for the cost of a review or reconsideration of a review, as determined under subsections (1) to (5), by such amount as is reasonable in the circumstances.

(8) The review committee may recommend a reduction of the additional amount payable for the cost of a review or reconsideration of a review if, in the course of the review or reconsideration, either of the following circumstances are found to exist:

1. The review or reconsideration relates to accounts that were submitted to the Plan by a physician or practitioner in accordance with advice received from the General Manager.

2. The General Manager or review committee failed to provide the physician or practitioner with information that was likely to affect either his or her decision to proceed with the review or reconsideration or his or her decision to make an offer to settle the matter.

38.2.3 Sections 38.2.1 and 38.2.2 apply to any review or reconsideration of a review under section 18.1 or 39.1 of the Act that is commenced on or after November 5, 1998 or that was commenced before November 5, 1998 but in respect of which a direction had not been issued before that date.

3. This Regulation shall be deemed to have come into force on November 5, 1998.