Claims Review – OHIP Eligibility Review Committee (OERC)
For claims submitted outside of existing deadlines, the OHIP Eligibility Review Committee (OERC) can review claims and determine possible extenuating circumstances for payment.
This committee can review both client and provider claim decisions made by Service Ontario or the Claims Services Branch. Generally,
- The OERC has the authority to overturn the original eligibility or payment decision
- However, it has no discretion and must assess requests for review according to the legislation/regulation, and cannot make exceptions that are not permitted under the Health Insurance Act or its regulations
- Requests for review by the OERC include providers who may have had an in-province claim rejected for payment for being past the six-month claims submission deadline (i.e., a “stale-dated” claim) as well as insured persons who may request a review of a claim that was denied payment (e.g., service not a benefit of OHIP, stale-dated, etc.)
Billing Irregularities – Ministry of Health and Long-Term Care’s Payment Accountability Unit
Billing irregularities come to the attention of the Ministry of Health and Long-Term Care’s Payment Accountability Unit as a result of:
- Calls to the fraud line from the public
- The return of adverse verification letters (letters sent out monthly by the verification letter program) to the Ministry, where a patient disputes a service billed by a provider
- Concerns identified by regional OHIP claims offices
- Internal Ministry verification of specific issues or known areas of problematic billing
- Concerns from regulatory bodies such as the various colleges
Irregularities are examined by the Payment Accountability Unit. This may include reviewing records and sending letters to patients to confirm a service rendered, in addition to a review of claims submitted to OHIP by a provider.
Suspicion of Fraud
When fraud is suspected, the matter is referred to the Risk Management and Fraud Control Unit of the Ministry who may, if circumstances warrant, forward it to the OPP.