One of Ontario’s top-billing doctors is facing professional misconduct charges from the province’s medical watchdog, which alleges he was incompetent in his care of patients and made inappropriate billings to the Ontario Health Insurance Plan.

The allegations against Chatham ophthalmologist Christopher Anjema, the fourth highest biller in Ontario in 2017-18, are laid out in a notice of disciplinary hearing Tuesday from the College of Physicians and Surgeons of Ontario.

Anjema’s questionable billings were featured in a recent Star investigation, which showed the doctor charged the province for performing an uncommon eyelid procedure at a frequency per patient an expert said is medically impossible.

“Dr. Anjema failed to maintain the standard of practice of the profession and/or is incompetent in his care of patients,” alleges the college in its notice.

The college alleges Anjema also “engaged in inappropriate submission of claims and/or billing to the Ontario Health Insurance Plan and/or to patients . . . which constitutes disgraceful, dishonourable or unprofessional conduct.”

None of the college’s allegations has been proven. A date for the disciplinary hearing has not been scheduled.

In a statement through a Toronto communications firm, Anjema said he “will continue to fully co-operate with the college, participate in its panel and attend its hearing which is the appropriate forum to address these matters in detail.”

The statement said Anjema “hopes that these proceedings will be scheduled as soon as possible so that he can provide comprehensive facts regarding the allegations which he is confident will result in an evidence-based outcome in the interests of the thousands of patients he is proud to serve in Chatham-Kent.”

The statement said the Anjema Eye Institute “provides global-standard quality eye care here in Ontario.”

The College of Physicians has been investigating Anjema’s “standard of practice” for more than year. In May 2018, Anjema agreed to perform cosmetic blepharoplasty (surgery sometimes referred to as eye lift or eyelid tuck) only under the guidance of a clinical supervisor while the regulatory body completed its probe.

Anjema, who billed OHIP about $4.1 million in 2017-18, has been among the top 10 billing doctors every fiscal year from 2011-12 to 2017-18, according to data provided by the Ministry of Health and Long-Term Care. Since 2011, he has billed more than $31 million.

Most doctors in the province receive at least some of their compensation under a fee-for-service model, in which physicians bill for each service they provide using a unique fee code.

This is done on the honour system.

Ontario spent roughly $6.7 billion on fee-for-service payments to physicians in the fiscal year 2017-18. The billings are not the doctors’ take-home pay and do not account for the often hefty overhead costs physicians pay for expenses such as equipment, staff salaries and rent. These costs come out of their billings.

Anjema operates a large eye centre in Chatham and a second clinic in Sarnia and employs a stable of administrative staff and technicians.

From 2011 to 2018, Anjema charged the province for performing 3,305 treatments under a fee code associated with a Tenzel flap, a reconstructive procedure for patients missing a piece of flesh from an eyelid, according to ministry billing data.

That’s more than all the other doctors in the province combined, including the oculoplastic surgeons who specialize in these kinds of procedures.

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“That’s more than most busy oculoplastic surgeons do in a career,” said Dr. Timothy McCulley, chief of oculoplastics surgery at the renowned Johns Hopkins Wilmer Eye Institute in Baltimore.

McCulley says he performs fewer than 10 Tenzel flaps a year. Anjema has billed for as many as 26 in a single day, according to the ministry data.

Anjema has not responded to repeated questions from the Star about his billings for the Tenzel flap procedure.

It’s not just the number of Tenzel flaps for which Anjema has billed that stands out. It’s also how many patients he claims have received it multiple times.

Anjema charged OHIP for two patients receiving the treatment 11 times each, according to the ministry’s data. More than 100 others had it done at least four times.

It’s “simply impossible” to perform a procedure like the Tenzel flap more than once per eyelid, said Dr. Howard Loff, a long-time oculoplastic surgeon in the U.S. and son-in-law of Richard Tenzel, the now deceased ophthalmologist who developed the “Tenzel flap” procedure decades ago.

A 2016 internal Ministry of Health audit honed in on Anjema’s “high volume (of) temporal flap rotation.” A temporal flap, which has remuneration of $514.80 per procedure, “is the same as a Tenzel flap,” confirmed the Eye Physicians and Surgeons of Ontario.

As part of the ministry’s audit, three external experts reviewed Anjema’s “poor” billing records and noted concerns the procedure’s fee code may have been used for “medically unnecessary services and services not rendered.”

In the weeks following the Star investigation, Anjema resigned from his position as head of ophthalmology at a Chatham hospital. The hospital’s president described Anjema’s departure as the doctor’s “personal decision.” A post made by Anjema’s Facebook account said the resignation stemmed from “a hospital bylaw issue.”

In 2017, the college gave Anjema a verbal caution on his clinical care and professionalism following a complaint from a patient. It also ordered him to complete a special continuing education and remediation program and be reassessed after six months.

One in a series of stories.