Ontario’s oversight of doctors’ billings has come under scrutiny, with instances of physicians billing for more than 24 hours in a day potentially diverting funds that could be used to recruit more family doctors, according to the auditor general. Shelley Spence’s annual report, released on Tuesday, highlighted several health-related audits, revealing low participation of family doctors in Ontario’s Health Care Connect system, crucial for achieving the goal of providing primary care to all residents. Furthermore, the report pointed out shortcomings in the government’s planning for medical school expansion.
In her examination of the health audits, Spence noted deficiencies in the Ministry of Health system, used by doctors since the 1980s to bill the Ontario Health Insurance Plan (OHIP), in automatically flagging high-risk billings despite significant technological advancements over the past decade. Spence emphasized the need for a review of the billing system to potentially recover funds for hiring additional family physicians. Analysis of claims over the past three years revealed instances where at least 59 doctors billed for more than 24 hours in a day annually, with a peak of 82 doctors in the 2024-25 period.
The report highlighted that the ministry had not thoroughly investigated these cases to determine their validity or if adjustments were required in time-based fee codes. Additionally, the ministry was found to be lacking in using hourly billing data to select doctors for audits, leading to uncertainty regarding the appropriateness of the billings. Notably, over 100 doctors in each of the last three years submitted claims for working every day of the year, with some physicians billing for services to more than 500 patients in a single day without facing post-payment audits.
While the ministry has conducted post-payment audits on high-billing doctors, uncovering significant overpayments in some cases, Health Minister Sylvia Jones was unavailable for comment. The government defended the complexity of the billing system, comprising approximately 5,000 different billing codes under the provincial health-care system. The auditor’s report raised concerns about the government’s reliance on a reactive approach, primarily responding to tips and complaints for identifying cases for audit.
Regarding the Health Care Connect system, which aims to link Ontarians with primary care providers by 2029, the report indicated that the system’s effectiveness fell short, resulting in prolonged wait times. Despite the government’s claims of reducing the waitlist, the auditor criticized the system’s inefficiency in addressing the true demand for primary care. Moreover, the report highlighted discrepancies in the government’s plan to expand medical school seats, indicating an underestimation of the population without primary care providers.
In conclusion, the auditor’s report underscored the need for improved oversight of doctors’ billings, enhanced efficiency of the Health Care Connect system, and a more accurate assessment of the demand for family physicians in Ontario.