We have recently become aware of Ontario physicians receiving letters from the Ministry of Health concerning what it describes as “HIGH VOLUME BILLINGS.” The letters don’t seek any repayment or call for any action, but simply let physicians know they are watching (with suspicion) how many days physicians work. What is notable about these letters is the reason physicians are being flagged: the “high number of days worked in a single year.”
Ontario physicians have long been subject to scrutiny of their OHIP billings. Most fee-for-service claims are paid on what is described as an “honour system,” after passing through computerized checks. Because those checks cannot determine whether every requirement for payment has been met, the Ministry may subsequently review physicians’ billing patterns and paid claims.
Historically, physicians have been accustomed to attracting attention because of the volume or type of services billed, or because billing patterns raise questions about whether the requirements for particular fee codes have been met. Time-based services are an obvious example: the Ministry’s own billing guidance identifies as a concern claims for time-based services that exceed “typical” office hours or a typical number of hours worked in a day.
But the letters we are now seeing are different.
The Ministry says that a physician’s billing has been identified as higher than that of physicians with similar practice profiles and identifies the “anomalous behaviour” simply as a high number of days worked in a single year. At the same time, the Ministry expressly acknowledges that billing data alone may not reflect the circumstances of an individual physician’s practice and that there may be legitimate explanations. OHIP is likely using some type of AI tool which is identifying not just high billing, but hard working physicians (based on their long days or lack of holiday).
Consequently, we are seeing dedicated physicians who regularly work seven days a week, or close to it, receiving this letter. For some physicians, a large number of working days does not reflect inappropriate billing. It reflects the reality of their practice and the demands placed upon them. It reflects their dedication to the patients in this province.
There is something troubling about sending a letter concerning “high volume billings” to a physician simply because the data suggests that they worked an unusually large number of days. I can imagine how many lawyers would get a letter like that from their regulator!
Of course, the Ministry has an important and legitimate role in protecting the integrity of the OHIP billing system which is funded by our tax dollars. Physicians are responsible for the claims submitted under their billing numbers, and claims must comply with the Health Insurance Act, and the applicable Schedule of Benefits for Physician Services requirements.
At a time when access to physicians remains a significant concern, we should be cautious about creating an environment where dedicated physicians become nervous because they are working hard or decide to reduce their wok habits rather than incur an audit.
While receiving one of these letters does not mean that the Ministry has determined that the physician billed improperly, this likely does not matter to the recipient. The letter asks the physician to review their billing practices and supporting documentation and says that the Ministry will continue to monitor billing activity. It states that further review may occur if unusual patterns persist or additional concerns are identified.
Physicians who receive one of these letters should take it seriously, but they should not accept that the fact that they work more days than most physicians means that they have done anything wrong. Before responding or taking corrective action, physicians should review their billings and documentation, understand precisely what has triggered the Ministry’s concern and, where appropriate, obtain advice about whether they are billing properly.
Sometimes an unusual billing pattern is a warning sign. But often, it is simply the pattern of a physician who works an unusual amount. The system needs to be able to tell the difference. If the system can’t tell the difference, that is one more reason why physicians are experiencing burnout (see: https://www.oma.org/advocacy/physician-burnout)
