The province’s 12 top-billing doctors — who received payments of between $2 million and $7 million in one year — are overcharging the Ontario Health Insurance Plan, documents obtained by the Star suggest.

A Health Ministry audit into their billing practices uncovered significant “concerns” about their claims to the taxpayer-funded plan.

According to the documents, six allegedly charged for “services not rendered,” five “upcoded” or billed OHIP using fee codes for more expensive procedures, and three charged for “medically unnecessary” services, which the plan is not designed to fund, the probe found.

The analysis shows the doctors, all specialists, billed an average of $4 million in fee-for-service claims between April 2014 and March 2015.

The top biller was an ophthalmologist who received $7 million. Health Minister Eric Hoskins said in April that this physician was paid $6.6 million, but the analysis shows an updated number. (Payments are not the same as income, as they do not take into account expenses for office rent, staff salaries and supplies.)

The remaining top billers include two additional ophthalmologists, three obstetrician/gynecologists, two diagnostic radiologists, two cardiologists, one anesthesiologist and one internal medicine practitioner. The names of the specialists are kept secret in the report, which the Star obtained through a freedom of information request.

The Star has been trying since April 2014 to have the names of the highest billers released. Earlier this year, the province’s privacy commissioner ruled in favour of an appeal by the Star, but three groups of doctors, including the Ontario Medical Association, are seeking to have that decision overturned. The case is headed to Divisional Court next year.

The ministry began its audit of the dozen top billers in late 2015 as part of a plan that calls for “better patient care through better value from our health-care dollars,” the report states.

A team of reviewers, which included three medical advisers and five external medical specialists, spent more than 3,000 hours analyzing more than 6,000 records, images and reports related to the “unique and highly complex” practices of the top billers, it says.

Among additional “concerns” alleged in the report:

Three specialists “inappropriately delegated” duties — for which they billed OHIP and which were supposed to perform themselves — to unqualified individuals to undertake.

Six claimed to have worked between 356 and 364 days of the year.

Eight recorded notably high volumes of claims and/or patients. One radiologist, who worked 332 days, billed for 100,000 patients, indicating that more than 300 scans were interpreted per day, the report stated.

Eleven billed OHIP incorrectly.

An obstetrician/gynecologist billed for seeing male patients.

It’s unclear from the report what the province is doing about the findings.

Part of the report, entitled “Recommended Action(s) and Next Steps,” was censored. Options given include: request repayment, fraud referral to the OPP, education, referral to the College of Physicians and Surgeons of Ontario, which regulates doctors, and referral to the Physician Payment Review Board, which holds hearings to resolve billing disputes.

A Health Ministry source, speaking on the condition of anonymity because they were not authorized to speak about the audit, said some of the cases have been referred to the college.

Hoskins was not available to comment on the report.

In an emailed statement, Dr. Virginia Walley, president of the Ontario Medical Association, which represents the province’s 30,200 doctors, said:

“The assumption that any physician has done something wrong before a formal process has been completed is detrimental and unfair. It is essential that all physicians have access to a just process.”

Walley referred to the organization’s turbulent relationship with the province. For close to three years, the two sides have been at odds, unable to negotiate a new physician services agreement. In the absence of one, physicians have no formal forum to discuss issues like this, Walley said.

“In an environment where Ontario’s doctors continue to be vilified by the provincial government, it is easy to jump to conclusions when looking at complex billing data. However, without all of the details about an individual physician’s practice, premature conclusions would be irresponsible,” she said.

Provincial auditor general Bonnie Lysyk made reference to the analysis of the top billers in her annual report released in November.

“The ministry suspected that some of these billings might have been inappropriate,” she wrote.

Lysyk said that two of the outliers, an ophthalmologist and a cardiologist, provided an extremely high number of diagnostic tests. She followed that up by saying a national campaign called Choosing Wisely discourages “unnecessary” diagnostic tests and treatments.

Loading... Loading... Loading... Loading... Loading... Loading...

These procedures, which are not supported by scientific evidence, can expose patients to harm, lead to more testing to investigate false positives, and contribute to patient stress, according to the Choosing Wisely campaign. As well, they put increased strain on the limited resources of the health-care system.

Lysyk urged the province to improve oversight of fee-for-service payments and to pay particular attention to “anomalies and outliers.” She recommended that the Health Ministry re-establish an “inspector function” to oversee billings.

The province has had no inspector function since 2005, when it disbanded its Medical Review Committee. That move was made on the recommendation of retired Supreme Court justice Peter Cory, who reviewed the committee’s auditing process and found it to be “debilitating and devastating” to physicians. His review followed the suicide of a pediatrician who had been audited.

The auditor general’s report said the ministry has challenges in managing and controlling the use of services billed under the fee-for-service system.

Fee-for-service claims are paid to physicians based on an honour system. Doctors are compensated based on a standard fee for each service performed, using fee codes from OHIP’s Schedule of Benefits.

“The Schedule of Benefits could be providing some physicians with an incentive to schedule patient visits and perform medical services strategically in a way that maximizes their billings,” Lysyk wrote.

Fee-for-service favours “procedural” specialists — those who perform procedures such as diagnostic testing and surgery — and those who generate high volumes of services, she noted.

Citing 2014-15 data from the Institute from Clinical Evaluative Sciences, Lysyk’s report showed that the highest OHIP billers are ophthalmologists, nuclear medicine specialists, radiologists and cardiologists.

There are big differences between what the highest billers and average billers in each of these specialties make, the report also revealed. In fact, the differences are among the largest of all specialties.

The government source said the ministry is “taking the auditor general’s comments very seriously and looking at its options.”

Earlier this month, Hoskins proposed a new funding deal to the OMA, which would have seen payments to some 500 physicians earning more than $1 million reduced by 10 per cent, while payments to 34 who earn more than $2 million would have been reduced by 20 per cent.

His plan called for redistributing savings from higher-paid physicians to lower-paid ones, including family doctors and specialists such as pediatricians, geriatricians and psychiatrists.

But the OMA rejected the offer, charging that it was “largely the same” as a tentative agreement overwhelmingly rejected by doctors in a ratification vote in the summer.

The OMA refuses to enter into negotiations unless the government agrees in advance to binding arbitration should the two sides reach an impasse. But the government says it will consider binding arbitration only as an item on the table during talks.

The OMA has not ruled out job action.

Hoskins’ plan would have also seen a 10-per-cent reduction in fees paid for services that can be performed more quickly now because of technological advances. For example, digital imaging technology allows X-rays, CT scans and MRIs to be interpreted faster. As well, cataract surgery and laser eye procedures don’t take as long to perform as they once did.

The government’s offer also called for modernizing the more than 7,000 fee codes in the OHIP Schedule of Benefits. Disparities between what different groups of doctors are paid have grown because technological advances allow some to work faster and bill OHIP more.