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PO-1933

Document		PO-1933


File #		PA-000372-1


Institution/HIC		Ministry of Health and Long-Term Care


Summary		BACKGROUND: The Ministry of Health and Long-Term Care (the Ministry) provided the following background information which is useful in understanding the discussion that follows: Under the Health Insurance Act ( HIA ), the General Managerof the Ontario Health Insurance Plan (OHIP) is responsible for executing the administrative functions of the Plan. This responsibility includes the payment of fee-for-service (FFS) claims to eligible physicians in return for the provision of services insured under the Plan. The Act also provides for a process of selected independent review of FFS claims by the Medical Review Committee (MRC). The HIA sets out the grounds under which the General Manager can refer claims to the MRC for review. The MRC can review a provider's claims for the following reasons: the service claimed for was not rendered, either in whole or in part, the service was misrepresented, either deliberately or inadvertently, the service provided was not medically/therapeutically necessary, or the service was not provided in accordance with the accepted professional standards and practice. The MRC is established by the HIA as a committee of the College of Physicians and Surgeons of Ontario (CPSO), but is funded by the ministry as a classified agency of the Ontario government. The MRC operates independently of the CPSO and the ministry in reviewing cases referred to it by the General Manager. In making a referral to the MRC, the General Manager specifies the physician in question, the fee codes of concern and the period of time for the review. During the course of the review, the MRC may have an inspector visit the physician's practice site(s) and review randomly selected medical records. The inspector will then prepare a report for the MRC who may then decide to invite the physician for an interview. At the interview, the MRC reviews a second set of randomly selected medical records. Following this process, the MRC considers all the information gathered and issues a direction to the General Manager. A direction may require that the physician repay funds for inappropriately submitted claims. MRC directions are binding upon the General Manager. ... In 1996, the HIA was amended to improve the consequences associated with an MRC direction to repay funds to OHIP. These consequences included the charging of interest on the repayment amount, charging of an additional amount to cover the cost of the review process, and providing the General Manager of OHIP with discretionary authority to release information pertaining to MRC reviews. NATURE OF THE APPEAL: The Ministry received a request from the media under the Freedom of Information and Protection of Privacy Act (the Act ) for access to "the number and names of physicians who inappropriately billed the system as identified by the medical review committee; their places of practice; and the amounts they inappropriately billed individually and collectively." In her request, the appellant explained that a 1996 amendment to the HIA had intended to make the names of these individuals public, but that there has been no disclosure since the amendment. The Ministry identified one responsive record. It consists of a chart listing 17 physicians by name, practice location, referral date to the MRC, the starting and finishing time period for the review of these physicians' billings, the date a final Direction was provided by the MRC, the total gross amount of fees recovered, and the recovery amount for post-May 1996 services. The record also lists the total post-May 1996 recoveries and the total gross recoveries of the 17 physicians. The Ministry issued a decision to the requester, granting access to the total number of physicians who were reviewed by the MRC and the total amount of funds recovered since 1996. The Ministry denied access to the remaining parts of the record on the basis that disclosure would constitute an unjustified invasion of the privacy of the 17 physicians under section 21(1) of the Act . The Ministry referred to section 21(1)(d) of the Act , and stated that it did not apply because section 18.1 of the HIA is discretionary. The requester (now the appellant) appealed the decision to deny access, and in her letter of appeal raised the possible application of the public interest override in section 23 of the Act . I sent a Notice of Inquiry initially to the Ministry and the 17 physicians identified in the record (the affected persons). I received representations from the Ministry. I also received representations from two affected persons and a lawyer representing the other 15 affected persons. None of the affected persons consented to the disclosure of information relating to them. I then sent the Notice to the appellant, together with a copy of the Ministry's representations and the non-confidential portion of the representations provided by the lawyer representing the 15 affected persons. I received representations from the appellant, which were then shared with the Ministry and the affected persons.The Ministry and the lawyer provided reply representations. RECORD: The only information at issue in this appeal is the undisclosed portions of the chart, as described above. PRELIMINARY ISSUE: Responsiveness of the Record In its representations, the Ministry states that the information relating to one of the physicians identified on the record is no longer responsive to the request. The Ministry explains: One of the physician's names has been deleted from the original record because an October 2000 amendment to the review period [for that physician], arising from a settlement, changed the review date such that the review period ended prior to May 1, 1996. Information pertaining to reviews involving services prior to May 1, 1996 therefore cannot be released. The appellant did not respond to the Ministry's position in her representations. I do not accept the


Legislation		FIPPA 21(1)(d) 21(3)(f) Section 23


Subject Index		financial transactions Health Insurance Act personal/professional differentiation severing personal identifiers


Signed by		Tom Mitchinson


Published		Jul 30, 2001


Type		Order


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