The Health Insurance Act is the Ontario statute that establishes the Ontario Health Insurance Plan (OHIP) and governs the public funding of insured physician and hospital services. In the discipline and regulatory context it is most relevant to billing: physicians bill OHIP under the Act and its schedule of benefits, and improper, excessive, or fraudulent billing can lead to recovery proceedings and to professional discipline.
Billing-related matters sit somewhat apart from the clinical negligence that drives most malpractice litigation, but they intersect with the profession’s integrity obligations and frequently feature in discipline cases alongside other findings. Distinguishing a billing or regulatory issue from a question of patient harm matters, because the former concerns the integrity of the public insurance system while the latter concerns compensation for injury through a civil claim.
Posts tagged Health Insurance Act analyze Ontario decisions and disciplinary outcomes involving OHIP billing and the public health insurance framework.
An emergency physician was struck off after billing OHIP $125,353 for services he never rendered, including critical care and cardioversions with no record they ever happened, and then refusing to cooperate with the College’s investigation. A look at why records integrity and the duty to cooperate sit at the centre of physician accountability.
HSARB upholds OHIP coverage denial for pectoral implant removal, applying the situs provision that excludes follow-up procedures at the site of cosmetic surgery.
A family physician was suspended for five months after using OHIP fraudulently while resident in New York. Discipline for non-clinical conduct under the HPPC.
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