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A Renewed Medical Review Committee: A New Legal Accountibility for Ontario's Physician's

Authored February 1, 2002

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The Ontario Health Insurance Plan’s billing audit process, as administered by the Medical Review Committee (MRC), has recently undergone substantial changes, due to legislative and policy amendments initiated by Ontario’s current government. In keeping with these changes, the Ministry of Health has also announced its intention to aggressively pursue physicians for alleged or perceived improper billing practices. These legislative and policy changes are eroding physicians’ rights to maintain a practice free from the threat of government regulators enforcing unfair policy.

If you think that you would never be the subject of an Ontario Health Insurance Plan (OHIP) audit, think again! More and more physicians are finding themselves faced with such a review. Some believe that the process affects only physicians who are inappropriately billing OHIP. This is a myth. Significant numbers of ethical physicians just like you are referred each year to the MRC, and 95% are ultimately ordered to repay substantial amounts of money to OHIP.

Dealing with an MRC review can occupy your time, energy and resources. Retaining legal representation in regard to such a review can be very costly. However, a cost-benefit analysis demonstrates the necessity of early, complete and intensive legal representation.

What is the MRC?

The MRC is a committee of the College, but it is not a self-governing body. The MRC is a creature of government, not a creature of the profession.

Generally, an MRC review may occur where the General Manager believes that all or part of the services billed by the physician were:

i. not rendered;
ii. misrepresented, whether deliberately or inadvertently;
iii. not “medically necessary,”
iv. not “therapeutically necessary;”
v. not performed in accordance with professional standards, vi. not submitted to OHIP in accordance with r vi. elevant regulations; or
vii. not submitted to OHIP in accordance with the Schedule of Benefits.

viii. How Has the MRC Process Historically Evolved?

Since its original creation and inception, the MRC process has undergone various changes, including the erosion of rules of fairness that once protected the rights of physicians involved in the process. In past years, physicians and their lawyers have been successful in arguing cases “on the merits” and consequently, overturned decisions of the General Manager on various medico-legal grounds. In these cases, physicians like you simply refused to accept MRC recommendations, and “fought back” by adjudicating the recommendations to the fullest extent of the law. Such legal challenges helped to make “good law” for the entire profession, helped to guide committees of the MRC itself, and also helped to keep the entire audit review process fair and reasonable. 

Unfortunately, recent changes to legislation, regulations and policy that began during the last term of the current provincial government have “rolled back” some of the fairness protections that had developed over the last 20 years.

How does an MRC Review Proceed?

There are two types of MRC reviews. The first is the typical “full review,” and the second is the “expedited review.”

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