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Fraud Against the Public Purse by Health Care Professionals: The Difference of Location Prepared By: Joan Brockman Research Paper May 2005 This paper was prepared for the Law Commission of Canada. The views expressed are those of the author and do not necessarily reflect the views of the Commission. Print the Research Paper (PDF, 528 KB)

Table of Contents

Acknowledgements

Executive Summary

PART ONE: Health Care Fraud: The Difference of Location

I. Research Methods

PART TWO: Defining the Problem of Health Care Fraud

I. The Range of Health care Fraud

II. Historical Concerns Over Fraud by Health Care Professionals

III. How Extensive is Health Care Fraud?

IV. The Social Control of Work

PART THREE: The Monitoring and Investigation of Medicare Billings in British Columbia

I. How Physicians are Paid in British Columbia

II. Disagreements Between Physicians and MSP

III. How Physicians’ Bills are Monitored in British Columbia

1. Billings Integrity Program (BIP) of the Medical Services Plan
2. Patterns of Practice Committee (POPC)
3. Audit and Inspection Committee
4. Medical and Health Care Services Appeal Board

IV. Criminal Prosecution

V. Discipline by the College of Physicians and Surgeons of British Columbia

PART FOUR: The Monitoring and Investigation Process in Ontario

I. How Physicians are Paid in Ontario

II. How Physicians’ Bills are Paid in Ontario

1. OHIP Monitoring
2. Medical Review Committee
3. OHIP Payment Review Program (OPRP)
4. Education and Prevention Committee (EPC)
5. Dissatisfaction with the MRC
6. Appeals to the Health Services Appeal and Review Board

III. The College of Physicians and Surgeons of Ontario

IV. Ontario Provincial Police Investigate Fraud by Doctors

PART FIVE: Cases of Fraudulent and Inappropriate Billing

I. Cases of Health Care Fraud and Inappropriate Billing in Canada

1. Parameters of Data Collection
2. The Cases
   1. Profession and Specialty
   2. Gender
   3. Age and Experience

II. Cases of Health Care Fraud and Inappropriate Billing in British Columbia and Ontario

1. Triggers to Investigation
2. Forms of Misconduct/Fraud
   1. Billings for Services Not Provided
   2. Up-coding
   3. Overservicing/Unnecessary Services
   4. False Diagnosis
   5. Patterns of Practice
3. Amount in Issue
4. Administrative Proceedings
5. SRO Proceedings
6. Criminal and Quasi-Criminal Proceedings
   1. British Columbia
   2. Ontario

PART SIX: Summary and Conclusions

I. The Difference of Location: The Monitoring Process In British Columbia and Ontario

II. The Difference of Location: Enforcement In British Columbia and Ontario

III. The Difference of Location: Professional Health Care Fraud and Welfare Fraud

IV. Lessons from Crimes of the Powerful

Bibliography

List of Tables

List of Cases

Appendix A: Coding Sheet for Cases in the Public Domain

Appendix B: Interview Schedule used in British Columbia

Appendix C: Glossary

Appendix D: Biography