Home Research Projects What is a Crime? Publications Fraud Against the Public Purse by Health Care Professionals: The Difference of Location PART FOUR: The Monitoring and Investigation Process in Ontario

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PART FOUR: The Monitoring and Investigation Process in Ontario [119]

I. How Physicians are Paid in Ontario

The Ontario Health Insurance Plan (OHIP), which was introduced in Ontario in 1972, is administered through the Ministry of Health and Long-Term Care (MOHLTC) (called the Ministry of Health between 1971 and 1999) [120]. OHIP pays for essential or insured services provided by physicians and some services provided by dental surgeons and physiotherapists. It also provides partial payment for services by podiatrists, chiropractors and osteopaths, and limited optometry services [121]. Physicians are paid for “insured services” according to a Schedule of Benefits for Physician Services under the Health Insurance Act, R.S.O. 1990, Chapter H.6. The schedule of fees is established by negotiations between the Ontario Medical Association (OMA) and MOHLTC [122]. In 2001-2002, approximately 23,000 physicians submitted 130 million claims to OHIP for $4.5 billion [123].

Under section 4 of the Health Insurance Act, a General Manager for OHIP is appointed by the Lieutenant Governor in Council to administer the legislation. The General Manager has the power, under section 4(2)(c) “to make payments by the Plan for insured services, including the determination of eligibility and amounts.” Under section 18(2), the General Manager may refuse to pay for a service or pay a reduced amount, if the General Manager is “of the opinion that all or part of the insured service was not in fact rendered,” the service claimed was “deliberately or inadvertently” misrepresented or “the service was not provided in accordance with accepted professional standards and practice.” The General Manager may also refuse to pay for services or pay a reduced amount that the General Manager “is of the opinion, after consulting with a physician, that all or part of the service was not medically necessary” or “not therapeutically necessary.” Under section 18(5), the General Manager may require reimbursement to the Plan for an amount paid for a service described in subsection 18(2). This “direct recovery” process, which allows the General Manager to pay all, part or none of a bill, was instituted in 1996.

II. How Physicians’ Bills are Monitored in Ontario

A. OHIP Monitoring

Staff in the OHIP offices (in the MOHLTC) monitor incoming claims for “duplicate claims, parallel procedures, frequent repeat visits or major assessments, recurrent billing for highly priced services, habitual laboratory tests, and office visits billed regularly and concurrently with minor diagnostic tests [124].” Some of this monitoring is done before payment [125], some after. OHIP staff are provided with reports that they examine in greater detail, looking at patterns of billing that may uncover “unnecessary or frequent repeat visits; undue use of or billing for expensive services; or high volumes of services, that may not be medically necessary or performed in accordance with appropriate standards [126].”

One contentious issue with such monitoring is that OHIP does not disclose to practitioners the computer programmes or statistical models that it uses to determine if a practitioner’s billings deviate from statistical norms. The OMA argues that if physicians knew what the acceptable norms were, they could bill more appropriately [127]. This is unlike the situation in British Columbia where the SRO’s POPC provides doctors with their billing profiles so they can adjust their billings to avoid an audit by the BIP based on patterns of billing. A recent detailed description of what OHIP looks for in computer-generated analysis [128] does not provide Ontario doctors with a preview of their billing practices relative to their peers as is provided in British Columbia. Physicians in Ontario were automatically provided with a summary billing profile prior to the mid-1990s that allowed them to compare their billings with their peers; however, they now have to pay for such information and it is “provided in a format that is cumbersome and difficult to interpret [129].”

The MOHLTC’s Processing Office takes the position that “physicians and practitioners are solely accountable for the propriety and accuracy of their claims to OHIP [130].” If OHIP staff is concerned about questionable billing practices, the General Manager has four options: 1) send letters pointing out the unusual billing pattern; 2) recover the funds under section 18(5) of the Act (without a review referral); 3) refer the matter to the Medical Review Committee (MRC) or other appropriate review committee [131], under section 39.1 of the Health Insurance Act; 4) if fraud is suspected, refer the case to the Ontario Provincial Police (OPP) [132]. The physician may appeal to the MRC to dispute a payment or lack of payment by OHIP (section 18.1).

B. Medical Review Committee

The MRC is established under section 5 of the Health Insurance Act as a committee administered by the College of Physicians and Surgeons of Ontario to review physicians bills when requested by the General Manager of OHIP (under section 39.1) or when requested by physicians (under section 18.1) [133]. Under the Act and Regulations, the Committee consists of 18 physicians nominated by the College of Physicians and Surgeons of Ontario and 6 public members, all appointed by the Minister. The MRC operates under what appears to be a confidential contract between the MHLTC and the CPSO [134].

In 2002, the Chair of the MRC explained how the Committee worked: “The Medical Review Committee gives those physicians, whose billing patterns catch the attention of OHIP, an opportunity to explain how they bill. If they can show that they are providing the services they say they are, great. If not, then the money has to go back in the pot [135].” More formally stated, the MRC “conducts an on-site audit, inspects the records of the services, interviews the physician who provided the service, determines whether the accounts were properly rendered in accordance with the statutory questions and if any repayment or increased payment to the referred physician is to be ordered [136].” The medical auditor’s Completed Inspection Report (CIR) is provided to the physician. Following receipt of the CIR, the MRC may conduct its own interviews and it will then make a binding direction to the General Manager of OHIP to pay the claims or require recovery of the money already paid [137]. The MRC review does not require a formal hearing; however, “the doctrine of deliberative secrecy applies to documents generated by members of the MRC during the decision-making process” (but not information gathered in support of its decision); and written reasons are required [138].

Following a review, the MRC may direct the General Manager to increase the amount paid or to require the physician to repay all or part of any payment (section 38.1(5)). A direction of repayment may be made:

1. If the applicable committee has reasonable grounds to believe that all or part of the insured services were not rendered.
2. If the applicable committee has reasonable grounds to believe that all or part of the services,
   1. were not medically necessary, if they were provided by a physician, or
   2. were not therapeutically necessary, if they were provided by a practitioner.
3. If the applicable committee has reasonable grounds to believe that the nature of the services is misrepresented, whether deliberately or inadvertently.
4. If the applicable committee has reasonable grounds to believe that all or part of the services were not provided in accordance with accepted professional standards and practice.
5. In such other circumstances as may be prescribed (section 39.1(6)) [139].

In 1996, a number of amendments to the Act expedited the process. In addition to direct recoveries (section 18), section 5(3.1), allowed the MRC to “sit in several divisions simultaneously, if a quorum of the Committee is present in each division.” A quorum is three members of the MRC, one of whom cannot be a physician. However, section 5(3) states that “one member who is a physician constitutes a quorum for the purposes of a review requested” under certain circumstances. Section 18.1(2) of the Act and 38.1(1) of the Regulations allow for a review by one member if the amount in dispute is under $100,000 or if the General Manager consents.

Further amendments in 1996 required that the referred physician pay interest [140] and some of the costs of the MRC review, which were previously paid by the Ministry. This led to many physicians opting to discuss settlement to avoid paying interest and the costs of hearings [141]. Following the amendments, the MRC offered physicians three options: a) settlement; b) expedited review; or c) regular or full review [142]. Given the increasing number of settlements, the MRC had the inspection report reviewed by a medical and public member of the MRC who make recommendations to the General Manager. The expedited review process involved no formal inspection, but an interview with one medical member of the MRC. This mechanism is seen as appropriate by the MRC for “straightforward cases involving only one or a very small number of fee schedule codes where the issues are straightforward and uncomplicated [143].” According to the MRC, the requirement that doctors pay the costs of a full review resulted in a dramatic drop of these reviews [144]. The reduction in the number of hearings and interviews has challenged the continuing expertise of the MRC, and so the MRC has increased its meetings and workshops to educate its members.

Table 1 shows that the number of regular and expedited reviews increased between 1998-2002; however, the MRC still only completed less than a 100 cases per year. This is in line with its contract with OHIP, but amounts to less than .5% of all physicians who bill OHIP.

Table 1
Number of Regular and Expedited Reviews by the MRC in Ontario, 1998-2002

Table 2 shows that the MRC recommended that OHIP recover over $36 million from 548 physicians between 1991 and 2002–an average of $3.3 million per year from an average of 49.8 physicians a year. The average amount recommended for recovery per physician was in excess of $66,449 and the average per physician ranged from $45,000 to $196,000 in any given year. The largest recommended recovery from one physician was $3 million in 1995-96 [145]. The amount recommended in 2001-02, $5.634 million, represented only .13% of the $4.5 billion paid out. According to the Co-Chairs of the MRC, “Clearly, Ontario physicians have an admirable record of accuracy in submitting their accounts [146].”

Table 2 [147] 
Number of Cases and Amounts Recommended for Recovery by MRC, 1991-2002

C. OHIP Payment Review Program (OPRP)

The OHIP Payment Review Program (OPRP) was introduced in January 2003, as a result of a joint review of the MRC by the MOHLTC and the Ontario Medical Association (OMA). The Joint Committee recommended that the auditing of physicians’ claims remain with the MRC, but that “a physician should be given the opportunity to attempt to reach an agreement with the ministry prior to a referral to the MRC.” The OPRP is optional, and physicians can always ask that their cases move directly to the MRC. A MOHLTC Bulletin points out some of the advantages of OPRP to a physician: “faster resolution of claim submission issues; fewer people involved; no additional charge for the cost of the review; interest starts after an agreement is reached, not at the end of the service period under review; and no publication of review information [148].

D. Education and Prevention Committee (EPC)

The Education and Prevention Committee, a joint effort by the MOHLTC and the OMA, was introduced in January of 2003, because of physicians’ concerns with the MRC [149]. Its “objective is to provide physicians with information about how to submit claims correctly,” thereby reducing “the need to recover payments for inappropriately submitted claims [150].” The EPC, which includes at least four members from the OMA and the MOHLTC, will make recommendations in areas including:

1. Principles on which to base further development of educational communication policy and billing matters.
2. Future steps to improve physician education in order to ensure appropriate claims to the Ontario Health Insurance Plan and thereby avoid misinterpretations based on the Schedule of Benefits.
3. Ensuring consistency and compliance of the educational policy with existing professional standards, and with the CPSO and ministry's policies pertaining to claims submissions.
4. Communication to physicians about the MOHLTC monitoring and control processes and activities.
5. Additional communication programs to improve physician awareness and understanding of claims issues [151].

E. Dissatisfaction with the MRC

In early 2003 [152], 400 physicians signed a letter complaining that the MRC process presumed that physicians were guilty until they proved themselves innocent, and that the requirement that physicians pay for the cost of audits was a denial of natural justice. They questioned the “peer” aspect of the review, since all but two of the members are appointed and paid by the MOHLTC and the “College rents the space occupied by the MRC to the MOHLTC. Thus, there is an apparent financial conflict of interest [153].” According to the letter, the MRC process has resulted in physicians suffering “financial hardship and permanent psychological after-effects. Bankruptcy, emigration, withdrawal from practice and marital breakdown are not uncommon.” The authors call for “a new independent tribunal, separate from the MOHLTC [154].”

In response to the letter, the Co-Chairs of the MRC clarified that much of what they do is enforce the rules, not create them. In addition, there is ample opportunity to avoid paying costs by resolving the issues prior to a full review. Furthermore, a fee-for-service system will not exist without an audit, and that the MRC system is much better than the one in the United States with “rewards for informants, fines for incorrect billing, and triple recovery.” If the audit is not done by the physicians’ SRO, it will be done by the government or the police. The Co-Chairs explained that they exist under “the auspices of an agreement between the OMA and MOHLTC,” and a recent one year audit by these organizations concluded that the MRC’s role in the audit process “should be continued and improved [155].”

The MRC, however, faced continuing criticism, including a home page for “MRC Victims [156].” The Ontario Physicians’ Alliance also went on the attack, referring to the “grotesque harassment” of doctors by the MRC, a “kangaroo court,” and calling for an “independent tribunal with the usual legal safeguards for those accused [157].” Some newspaper reports implicated the MRC in the suicide death of Dr. Anthony Hsu in April, 2003. Dr. Hsu had been ordered to repay $108,000 because of inaccurate billing to OHIP [158].

On May 23, 2003, the President of the College of Physicians and Surgeons requested the Minister to conduct an external and independent review of the entire audit process, including the criteria used by OHIP in referring cases to the MRC, the composition of the MRC, the criteria MRC use to decide to perform an audit, the cost recovery provisions and so on. On April 30, 2004, the Ontario government appointed the Honourable Peter Cory to review the MRC’s practices and to make recommendations regarding the audit system [159].

In preparation for their submissions to Justice Cory’s Review, the OMA surveyed its 25,000 members and found that there was much dissatisfaction with the review process. Physicians wanted the process to be more transparent, shorter, less arbitrary, and more reasonable in terms of its record-keeping demands, and they wanted a more comprehensible Schedule of Benefits. Physicians were concerned with the way the audit process targeted certain fee codes and specialities and thought the dollar recovery amounts were too high. They also thought the onus of proving billing errors should be on the MHLTC and that no amounts should be payable until all appeals were exhausted. There was also a concern that doctors were leaving Ontario or not coming to Ontario because of the auditing practices. The OMA concluded that a “best practices” audit system would be “fair, open and transparent in administration and adjudication, independent, objective, competent, reasonable, and timely.” In addition, there should be no recovery from a physician who is practising “in accordance with prevailing standards of care [160].” The OMA believes that the audit process should focus on education and prevention, and that physicians should be given six months to alter their billing behaviour if the Ministry is not satisfied with the physicians’ explanations of their billing behaviour. According to the OMA, physicians should have knowledge of the statistical norms expected of them so they can bill accordingly [161].

In its submissions to the Cory Review, the OMA suggested that direct recoveries by the General Manager should be abolished as there is no hearing or procedural protection for the physicians [162]. Both the College and the OMA recommended that the expedited review before one panel member be abolished. The notion of peer assessment was key to the OMA’s submissions.

In their submissions to Justice Cory’s Review, the Coalition of Family Physicians of Ontario described the audit system as “inquisitional” and “abhorrent to our common law traditions of fairness and justice.” It resulted in physicians being “demoralized, dejected and insulted” by their experiences with it [163].

F. Appeals to the Health Services Appeal and Review Board

Physicians who are dissatisfied with decisions of the MRC can appeal to the Health Services Appeal and Review Board [164]. Between 1994 and 2004, the Board opened 70 files. Most cases were either settled or the appeals were withdrawn; only seven proceeded to a determination by the Board. Of those seven, six were heard and decided in 2003-2004 [165]. The seven cases are included in the analysis of cases in the public domain under Part V.

III. The College of Physicians and Surgeons of Ontario

The College of Physicians and Surgeons of Ontario (CPSO), the self-regulating body of doctors in Ontario, is established under the Medicine Act, S.O. 1991, Chapter 30. The College is governed by a Council of 15-16 doctor members, 13-15 public members appointed by the government, and three faculty members from faculties of medicine in Ontario (section 6). The Council may delegate matters to an Executive Committee, composed of four doctors and two public members (section 27), and three members constitute a quorum (section 29).

In addition to its role in the MRC, the College also has disciplinary powers over its members who engage in professional misconduct [166]. Professional misconduct includes fee-splitting, falsifying medical records, signing or issuing a misleading or false document, charging for services not performed, charging excessive fees, failure to itemize professional services when requested, contravening a federal or provincial law that is relevant to the physician’s suitability to practise medicine, and any act or omission that is “disgraceful, dishonourable or unprofessional [167].” The College’s practice is to take disciplinary action against doctors after they are convicted of OHIP fraud [168].

IV. Ontario Provincial Police Investigate Fraud by Doctors

If OHIP staff suspect fraud, they can refer the matter to the Ontario Provincial Police (OPP). The OPP’s Health Fraud Investigation Unit, which was created in April, 1998, doubled in size from nine to 20 in the first year. From 1998-2000, 500 cases were referred to the Unit, including 60 cases of alleged fraudulent billing by health care professionals. In 2000, the Unit was “pursuing 10 cases of alleged fraud by physicians and pharmacists in the courts; the fraud involve[d] an average of about $800,000 per case.” The Unit also has proceeds of crime investigators who will pursue property bought by doctor’s “ill-gotten gains [169].” By 2001, the OPP had 28 members in its OHIP fraud squad, and 13 of them were assigned to investigating physicians’ billings [170]. It was also reported that since inception, 25 charges were laid–15 were before the courts, one was stayed and nine physicians were convicted [171]. By 2002, 18 physicians had been convicted [172].

[119] As indicated in the introduction, the Ontario legislature passed The Transitional Physician Payment Review Act, S.O. 2004, C.13, on June 24, 2004 which halted all audits conducted by the Medical Review Committee until after Justice Cory’s review and report. This section discusses the audit process as it existed prior to June 24, 2004.

[120] Ministry of Health and Long-Term Care, “About Ministry of Health and Long-Term Care”www.health.gov.on.ca/english/public/ministry/about.html; accessed September 16, 2003.

[121] Ministry of Health and Long-Term Care, “Health Services: What's Covered by OHIP” www.health.gov.on.ca/english/public/pub/ohip/services.html; accessed September 16, 2003.

[122] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 1.

[123] Ministry of Health and Long-Term Care, “Health Update: Reviewing OHIP Claims: Ensuring Accountability for Ontario's Healthcare System” www.health.gov.on.ca/english/public/updates/archives/hu_03/hu_ohip.html; accessed September 16, 2003.

[124] “Medical Review Committee: A Peer Review of Physician Billings” (September/October 2002) Members' Dialogue www.cpso.on.ca/publications/dialogue/0902/mrc.htm; accessed September 18, 2003.

[125] The computer rejects about $10 million in claims each month; MHOTC

[126] “Medical Review Committee: A Peer Review of Physician Billings.”

[127] Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review 24 (I have used page numbers 1-12 from a printed online version). When this issue was raised before the Health Services Review and Appeal Board, it stated that it did not have jurisdiction to review OHIP’s decision to refer a matter to the MRC, but rather that was an issue for the courts as it was limited to reviewing MRC decisions; Carstoniu v. The General Manager, Ontario Health Insurance Plan (Health Services Review and Appeal Board; August 13, 2004; 03-HIA-0050) at 25.

[128] Garry Salisbury and Larry Patrick (Co-Chairs) “Post-Payment Review and Auditing of OHIP Claims–Part B The Claims Review Process” (September, 2003) Ontario Medical Review online: www.oma.org/pcomm/omr/sep/03bulletin.htm; accessed August 29, 2004.

[129] College of Physicians and Surgeons of Ontario, “Submissions to The Hon. Peter Cory, Reviewer of Ontario’s Medical Audit System” (13 July 2004) at 11.

[130] MOHLTC, Processing Office, “Medical and Practitioner Review Committee Activity” Bulletin No 4383 (April 1, 2002) at 1.

[131] There are five peer review committees: medical, chiropody, chiropractic, dentistry and optometry; however, the MRC receives most of the work.

[132] MOHLTC, Processing Office, “Medical and Practitioner Review Committee Activity” Bulletin No 4383 (April 1, 2002) at 1.

[133] The MRC was first created in 1971; Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review (online: www.petercory.org).

[134] The OMA has requested, but never received, the contract; Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review (online: www.petercory.org).

[135] “Medical Review Committee: A Peer Review of Physician Billings” (September/October 2002) Members' Dialogue www.cpso.on.ca/publications/dialogue/0902/mrc.htm; accessed September 18, 2003.

[136] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 2.

[137] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 3.

[138] Carstoniu v. The General Manager, Ontario Health Insurance Plan (Health Services Review and Appeal Board; August 13, 2004; 03-HIA-0050) at 19-23.

[139] If the MRC discovers quality of care issues, it will refer them to the College’s Registrar which may take action; College of Physicians and Surgeons of Ontario, “Submissions to The Hon. Peter Cory, Reviewer of Ontario’s Medical Audit System” (13 July 2004) at 4.

[140] The interest, in a prescribed amount, is payable from the date determined in a prescribed manner (section 18.1(14)).

[141] There were some changes retroactive to April 1, 2003, in the amount of costs that the physician must pay; however, costs are still a contentious issue in Ontario; College of Physicians and Surgeons of Ontario, “Submissions to The Hon. Peter Cory, Reviewer of Ontario’s Medical Audit System” (13 July 2004) at 10 (online: www.petercory.org).

[142] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 3.

[143] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 4.

[144] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 5.

[145] Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report, April 1, 2000-March 31, 2001 at 13.

[146] Drs. Barry Giblon and Rachel Edney, Co-Chairs of the MRC, Respond to “Dear Editor: Re: Medical Review Committee: A Peer Review of Physicians Billings–Sept/Oct 2002” (2003) Members’ Dialogue 7 at 9.

[147] Numbers taken from the Medical Review Committee of the College of Physicians and Surgeons of Ontario, Annual Report (April 1, 2001 to March 31, 2002) at 5. I was unable to access the MRC web site for an update on these statistics on October 16, 2004 because it is now only accessible with a password.

[148] MOHLTC, “OHIP Payment Review Program” (January 16, 2003) Bulletin Number 4396.

[149] “New initiatives aim to improve billing processes and reduce risk of MRC referral” www.oma.org/pcomm/omr/dec/02agreement.htm (accessed September 20, 2003).

[150] Ministry of Health and Long-Term Care, “Health Update: Reviewing OHIP Claims: Ensuring Accountability for Ontario's Healthcare System” www.health.gov.on.ca/english/public/updates/archives/hu_03/hu_ohip.html; accessed September 16, 2003.

[151] “OMA_MOHLTC Agreement Update” www.oma.org/pcomm/omr/may/02agreement.htm; accessed September 20, 2003.

[152] Dissatisfaction by physicians did not commence in 2003, rather it has a fairly long history. Some of this can be seen in the Ontario Medical Review, a publication by the OMA in which agreements between the OMA and MOHLTC are discussed.

[153] Some doctors also seemed concerned that the MRC was too connected to the CPSO. One of the recommendations of a joint OMA-MHLTC Committee on the MRC was that the MRC function remain with the CPSO, but that the MRC make it clear to physicians that it is separate from other CPSO functions.

[154] “Dear Editor: Re: Medical Review Committee: A Peer Review of Physicians Billings–Sept/Oct 2002” (2003) Members’ Dialogue 6 at 6-7.

[155] Drs. Barry Giblon and Rachel Edney, Co-Chairs of the MRC, Respond to “Dear Editor: Re: Medical Review Committee: A Peer Review of Physicians Billings–Sept/Oct 2002” (2003) Members’ Dialogue 7 at 10.

[156] “MRC Victims Home Page” www3.sympatico.ca/dindar/mrc/mrc.htm; accessed September 19, 2003.

[157] “01/03/2003 Entry: "how bad it is” www.opaonline.org/gmatter/archives/00000012.html; accessed September 19, 2003.

[158] Peter Downs, “No moratorium on doctor audits” (17 May 2003) The Review (Niagara Falls) A1; Allan Benner, “’They know it is a faulty system’” (16 May 2003) Tribune (Welland) A1.

[159] Terms of Reference, April 30, 2004; www.petercory.org; accessed December 30, 2004.

[160] The OMA was of the view that given the record-keeping requirements, the current system “would mandate a recovery from virtually any Ontario physician reviewed by it;” Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review (online).

[161] Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review (online). The OMA actually uses the word “appropriately” not “accordingly” but there is a fine line between the two. The reference to the purpose of the audit process as “education and prevention” is repeated in the OMA’s submission at pages 3, 7 and 9.

[162] Ontario Medical Association, “OMA Submission to the Honorable Justice Cory–Review of the Ontario Medical Audit and Review Process” (July/August, 2004) Ontario Medical Review at 4.

[163] Coalition of Family Physicians, “Enshrining Confidence: COFP’s Submission to Justice Peter Cory” at 2-3.

[164] Health Insurance Act, R.S.O. 1990, C. H-6, section 20(1).

[165] Letter from Beverly A. Harris, Chair, Health Services Appeal and Review Board to The Honourable Peter Cory, dated September 27, 2004 (online: www.petercory.org).

[166] Section 51, Schedule 2, Health Professions Procedural Code.

[167] Ontario Regulation 856/93 as amended by Ontario Regulation 53/95 under the Medicine Act, 1991.

[168] See cases discussed under Part V.

[169] Barbara Sibbald, “MDs Get Jail Terms, Fines as New Police Squad Targets Health Fraud” (2000) 163(5) Canadian Medical Association Journal 591.

[170] Editorial, “Policing physician fraud” (26 April 2001) The Ottawa Citizen A17.

[171] Editorial, “Policing physician fraud” (26 April 2001) The Ottawa Citizen A17. Not all of these cases would necessarily be OHIP fraud.

[172] Ellie Tesher, “Stepped-up OHIP audit taints doctors” (7 March 2002) The Toronto Star A31.