Chatham ophthalmologist Christopher Anjema has billed the Ontario Health Insurance Plan for treating patients suffering from common eye problems such as cataracts and glaucoma.

He has also charged the province for doing a not-so-common eyelid reconstruction procedure — again and again.

Known as a Tenzel flap, it’s performed when a patient is missing a hunk of flesh from an eyelid, often because cancerous skin had to be removed. The surgeon makes a small, semicircular incision beside the eye to be able to slide some extra tissue over to repair the eyelid.

Anjema, one of Ontario’s top-billing doctors, charged the province between 2011 and 2018 for 3,305 treatments under the fee code associated with the Tenzel flap, according to billing data released by the Ministry of Health and Long-Term Care.

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

“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, who refused repeated requests for comment from the Star, has billed for as many as 26 in a single day, according to the ministry data.

A Star investigation has found Anjema and at least two other top-billing doctors have charged tax-funded OHIP for procedures or tests at frequencies much higher than what experts say is standard or, in some cases, even possible.

At least two of the doctors’ billings were flagged by an internal Ministry of Health audit in 2016, which examined whether they were “upcoding” — charging OHIP using fee codes for more expensive procedures.

The audit noted concerns that the high-billing doctors may be charging for procedures that were “medically unnecessary” or had not actually been done. One of the doctors says the auditors found “nothing improper” with his billings.

Despite the government’s scrutiny, the two doctors continued billing for the treatments at high frequencies, the Star has found.

The payments have persisted under a flawed oversight system, which critics say prioritizes sending education letters to doctors about their concerning OHIP charges over policing improper billing.

Fee-for-service compensation, in which doctors bill OHIP for each service they provided using a unique fee code, is done on the honour system.

“The whole system is based on trust, and that gives a wonderful opportunity for someone to take advantage of that trust,” said Joan Brockman, a Simon Fraser University professor who has researched health-care fraud in Canada.

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

When limited health-care dollars are spent where they’re not needed, it takes away money from other medical services, Brockman said.

“One of the major impacts is there are all kinds of medical services that aren’t being provided because there is not enough money,” she said. “There is lots of money in the system if you just went out and found it.”

The Star obtained extensive data for the 100 top-billing doctors for fiscal years 2011-12 to 2017-18. In total, 194 physicians were included in the database, which details each fee code they billed, an anonymized patient ID, the date and the amount billed. The data does not include the patients’ diagnoses.

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In an online bio, Mississauga doctor Narendra Armogan is described as an “internationally recognized leader” in ophthalmology and a trailblazer responsible for “leading several surgical firsts in Canadian medical history.”

He was also the top-billing doctor in Ontario every year from 2011-12 to 2017-18 except for one. That year, in 2016-17, he ranked third.

Over seven years, he charged OHIP more than $42 million for assessing, testing and treating patients, according to ministry billing data. A portion of those billings go toward overhead, which Armogan says “include at least 50,000-plus square feet, over 70 staff and probably more equipment than any other practice in Canada.”

During that time, the procedure he billed the most money for was a laser treatment called photocoagulation.

Billed under fee code E154 (with a remuneration of $182.75 per service for one eye), this laser procedure is used to treat a range of problems including a blood blockage in the eye’s veins and diabetic retinopathy.

Retinopathy is a common eye disease for diabetics. Over time, high blood sugar levels weaken the tiny blood vessels within the retina, the thin layer of tissue at the back of the eye that converts light into neural signals so the brain can interpret what is being seen.

The damaged blood vessels starve the retina of oxygen. In a bid to improve blood circulation, abnormal blood vessels may start to grow, but these are fragile and prone to rupturing, causing serious vision loss or even blindness.

The standard treatment for a severe case is to use a scatter laser, also known as pan-retinal photocoagulation, to minimize oxygen demand.

It’s a tradeoff: deliberately destroy part of the peripheral retina to save the eye from irreversible vision loss. A patient loses some peripheral vision but in most cases not enough to affect their daily life.

“You’re essentially burning the peripheral retina with the laser so the tissue is obliterated,” said Dr. Leo Kim, a professor at the Harvard Medical School and surgeon with Massachusetts Eye and Ear hospital.

“There is only limited real estate there.”

The average patient would receive this pan-retinal photocoagulation over the course of about two to eight laser treatments per eye, according to Kim and five other ophthalmologists interviewed by the Star.

These experts included the lead author of Canada’s clinical guidelines on managing diabetic retinopathy and members of the committee that produced a handbook on retinal care for Ontario’s health ministry.

The lasering is uncomfortable — it’s been likened to an intense ice-cream headache — so a patient with a low pain tolerance might need more sessions.

But as there’s only so much tissue in the peripheral retina a doctor can laser, “you run out of retina to treat,” said Dr. Sherif El-Defrawy, chair of the University of Toronto’s department of ophthalmology and ophthalmologist-in-chief at Toronto’s Kensington Eye Institute.

“After the entire periphery of the retina has been treated, further laser therapy of this area would be ineffectual,” he said.

Six ophthalmologists told the Star that the worst-case patient they could imagine, who suffers from multiple eye problems in both eyes, may warrant at the most 30 to 40 photocoagulation treatments in total.

Armogan, the province’s top-billing doctor, routinely charged for that and more, ministry data shows.

From fiscal years 2011-12 to 2017-18, more than 500 of his patients received retinal lasering at least 40 times, according to the ministry’s billing data. For some patients, two treatments were billed in one session in what’s known as a bilateral procedure, which may be used when a doctor does the same procedure on both eyes during the same appointment.

Armogan charged OHIP for two of those patients getting the lasering more than 200 times each, the ministry data shows.

In written responses, Armogan called the Star’s analysis of his billing data “flawed and grossly incorrect.” He said he has no recollection of any of his patients receiving pan-retinal photocoagulation treatments more than 100 times each.

Armogan says the photocoagulation laser fee code can be used when treating more than 20 different ocular conditions, including fixing retinal tears and sealing leaking blood vessels that cause swelling of the macula, essential for sharp central vision.

His clinic has spent millions of dollars on cutting-edge laser systems, he said. With a micropulse laser, he uses a “subthreshold” treatment method featuring low-intensity shots, “which is clinically effective” without causing detectable injury to the retina, he said.

“This absence of retinal damage allows for unlimited retreatment,” Armogan said. “With this in context, it is clear why my partners and I use this type of laser treatment routinely.”

Armogan described his “skills as a versatile laser expert” as “unmatched.”

He said he employs a range of different laser settings and techniques to help patients avoid needing surgery or medications injected into their eyes, which he says are costlier to the health-care system.

“The concept that there is a ‘fixed number’ of laser treatments is foreign to me since every patient is different,” he said.

By “titrating (patients’) laser treatments to ensure a successful outcome,” he avoids “rushing and subjecting them to unnecessary surgeries and injections,” which Armogan said come with more risk.

In breaking up lasering into multiple “manageable, lower energy” sessions, there is less pain for the patient, Armogan said, which he said leads to a higher number of patients completing the treatment.

Armogan said he treats “numerous complex patients” with multiple serious eye problems, adding that it’s impossible to fairly assess the treatments his patients received without their accompanying medical charts, which the ministry’s data does not include.

A typical retinal photocoagulation treatment takes roughly 15 minutes, including the time spent preparing the patient and documenting what was done, said Dr. Bernard Hurley, a retina specialist at the Ottawa Hospital’s Eye Institute.

An efficient ophthalmologist with a dedicated “laser day” could do as many as six to 12 an hour, Hurley said.

On one day in October 2012, Armogan billed for 128 photocoagulation treatments on a total of 83 patients, the ministry data shows.

At 12 per hour, that would take more than 10 straight hours with no meals or bathroom breaks for one doctor to do.

On top of that, Armogan billed for tests, assessments and procedures related to an additional 144 patients that same day, according to the ministry’s data.

The date of a billing should reflect the day the service was provided, the ministry of health said.

Physicians are expected to bill only for services such as assessments, surgical procedures and the interpretation of test results that they personally performed. There are some “delegated” services, such as drawing a blood sample, that can be performed by trained staff as long as the doctor is around to ensure they’re done competently, the ministry said.

Armogan did not respond to questions about the 128 laser treatments billed in a single day, as the ministry data shows.

He told the Star “there are no members of staff who use my billing number” to charge OHIP.

A doctor performing more than 100 retinal laser treatments in addition to assessing or treating 144 other patients in a single day is unquestionably an outlier, said El-Defrawy of the University of Toronto.

“Those numbers do raise my eyebrows. Logistically, they don’t make much sense,” he said.

El-Defrawy said ophthalmology as a specialty has been transformed over the last decade or so with efficiencies, allowing some doctors to see many more patients than previously possible.

“But these numbers seem far in excess of that,” he said.

In a 2016 audit into the province’s 12 top-billing doctors, the Ministry of Health noted that Armogan’s clinic has a “very efficient business model.”

The ministry redacted the names of the doctors from its audit, which was obtained by the Star under Freedom of Information legislation. The Star identified the doctors by matching the descriptions of their days worked, patients seen and their income rank with the physician billing data.

The auditors examined Armogan for allegedly upcoding and billing incorrectly, and homed in on the doctor’s “high frequency of retinal photocoagulation per patient per year.” The audit noted concern of “medically unnecessary procedures” including retinal photocoagulation.

The audit says Armogan’s records were “evaluated as satisfactory.”

It’s unclear what, if any, conclusions auditors reached about Armogan and other doctors’ billings as the ministry kept secret the section describing “recommended action” that was taken. The ministry’s options included educating doctors on proper billing practices, asking money be repaid or referring a case for investigation.

Armogan said in a statement that he is happy to answer questions from the province about his clinic’s operations.

“The ministry has asked many questions, including some in 2016,” he said. “They found nothing improper.”

Armogan bristled at the Star’s questions about his billing patterns.

“The problem in this situation is that you are seeking information that is not in the public interest at all,” he said.

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“I also provide what I believe to be a vital service, and in fact an indispensable public service to the citizens of Ontario. I save sight,” Armogan continued. “You are conducting a hatchet job to destroy my reputation and … livelihood.”

Armogan’s OCC Eyecare Mississauga clinic, a three-storey building not far from Pearson International Airport, is often bustling with patients. Armogan is one of six doctors listed on the clinic’s website. OCC Eyecare also has a clinic in Vaughan.

Over the seven years of billing records analyzed by the Star, Armogan averaged more than 140 patients per working day. Some of those patients underwent procedures, while others were there for tests or assessments.

On one day in March 2018, Armogan billed for 249 separate patients, according to the ministry data.

Armogan told the Star his clinic regularly asks “for input from our patients and their approval ratings consistently exceed 95 per cent.”

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Every day for five straight years, Dr. Dalia Rosen-Zaidener billed OHIP, according to the ministry’s data.

Rosen-Zaidener treats patients at multiple clinics operated by Canadian Addiction Treatment Centres (CATC), a chain of approximately 70 methadone clinics owned by a U.S. health-care company.

She said she has consistently worked seven days a week to fill a health-care gap in rural areas for patients suffering from opioid addiction, “a public health crisis that is plaguing our country.”

“I felt personally obligated to help, making many sacrifices to dedicate most of my waking hours to helping people who were destined to become an overdose statistic,” she wrote in an email to the Star.

Her billing records show some of her patients are undergoing urine drug tests at a greater frequency than what some addiction doctors say is medically necessary.

Read more from the Star’s Operation Transparency series:

They’re Ontario’s top-billing doctors, but for years their identities have been kept secret. Until now

Revealed: Ontario’s Top 10 highest-billing doctors

Of the 194 highest-billing doctors in Ontario, 54 are ophthalmologists. Why?

Provincial guidelines across Canada generally recommend patients receive frequent urine screens when they begin treatment, so the doctor can check for the presence of other drugs and adjust the dosage if necessary.

Once a patient has stabilized, generally after several months of treatment, urine tests can be reduced from weekly to monthly, or even less frequently, guidelines say. The doctors follow a similar practice at CATC, Rosen-Zaidener said.

Yet more than 50 of Rosen-Zaidener’s patients have undergone twice-weekly urine tests for years at a time, according to OHIP billing data. A handful of her patients have provided urine samples twice a week for five straight years.

A 2016 report by a provincial methadone treatment advisory committee found no evidence that sustained frequent urine tests improve patients’ clinical outcomes.

Instead, these “burdensome requirements ... can severely restrict a patients’ ability to conduct daily living activities” because they spend so much time travelling and waiting around the clinic, the committee’s report said. This can lead to frustrated patients dropping out of the treatment program, said Dr. Meldon Kahan, co-chair of the advisory committee and medical director of substance-use service at Women’s College Hospital in Toronto.

The advisory report also warned that OHIP’s fee schedule, which will pay for as many as nine urine tests per patient each month, “incentivizes clinics to require patients to provide frequent urine samples and attend frequent office visits.”

Rosen-Zaidener said by email that stabilization “takes different lengths of time for each patient and is addressed using an evidence-based approach.”

She said her demanding patient load prevented her from answering questions about her billings in more detail, adding that the Star’s analysis of her OHIP billing data appeared “flawed.”

Of the roughly $8.7 million Rosen-Zaidener charged OHIP for all her billings from fiscal years 2013-14 (her first year among the top 100 billers) to 2017-18, more than half of the payments were for urine tests, which do not require the doctor to interact with the patient. (More than 50 per cent of those billings go toward overhead costs of running the clinics, the doctor said.)

Of the 194 doctors included in the ministry’s data, Rosen-Zaidener ranks 62 in total dollar amount billed.

Each month, a doctor can bill OHIP $15 for each of a patient’s first five urine tests (fee code G040) and $7.50 for the sixth to ninth tests (G043).

That compensation is substantially less than what it was. In 2015, the government, feeling it was shelling out too much for a simple test, cut remuneration in half, a move some doctors said hurt patients and led a number of addiction treatment clinics to reduce their services or close altogether.

The first full fiscal year following those cuts, the dollar amount Rosen-Zaidener billed for urine tests dropped by 20 per cent.

Dr. David Marsh, medical director for CATC, said the clinics provide excellent care to their patients. He said he was not concerned that the billing data showed some patients underwent frequent, ongoing urine tests because there will always be a small number of patients whose needs go beyond what’s outlined in treatment guidelines designed for “general, common situations.”

“The frequency of the urine drug screens is less important than what you do with the results,” he said.

At his clinics, he said urine tests are “tied to” a stable patient getting upwards of six take-home doses of methadone, a potent opioid itself.

“If (Ontario’s) going to have liberal take-home policies that allow patients who are stable to get back to work, one of the risks is that some of that methadone will be diverted and people who are not methadone patients may die from methadone overdoses,” Marsh said.

“(We) need to do a lot of urine drug screening to make sure those patients are safe and other members of the public are safe.”

Dr. Robert Tanguay, who leads opioid dependency treatment training for Alberta Health Services, said urine tests are too often relied on by doctors instead of taking the time to build a relationship with a patient.

“There is no evidence to suggest that making someone do twice-weekly urine screens reduces death rates,” Tanguay said. “The only value is in the pocketbook of the physician or the clinic owner.”

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Back in Chatham, ophthalmologist Christopher Anjema’s anomalous billing has previously come under review.

In its 2016 audit of 12 top billers, the ministry zeroed in on Anjema’s “high volume (of) temporal flap rotation” (fee code E227, $514.80). A temporal flap “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.”

And Anjema remains under scrutiny.

In May 2018, the College of Physicians and Surgeons of Ontario began investigating Anjema’s “standard of practice.” During the probe, he can perform cosmetic blepharoplasty procedures — sometimes referred to as eye lifts — only “under the guidance of a clinical supervisor acceptable to the college.”

The OHIP billing data obtained by the Star is as recent as March 2018. That month, Anjema billed for the fee code associated with the Tenzel flap 12 times.

Over seven years, he charged the province more than $1.6 million for that fee code — part of the more than $31 million he billed in total.

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. who now owns multiple health-care companies.

Loff is also the son-in-law of Richard Tenzel, the now deceased ophthalmologist who developed the “Tenzel flap” procedure decades ago.

“There is no question: once you do it, you can’t repeat that same procedure on that eyelid. That tissue is not available anymore to be rotated over,” Loff said.

“It just defies logic.”

One of an ongoing series of stories.