Post-Payment Accountability Steering Committee

Mandate

In January 2020, the Physician Services Committee (PSC) established the Post-Payment Accountability Steering Committee to oversee the implementation of changes to the administration of OHIP payments and related processes, specifically through development of the policies and procedures associated with the audit process, and educational materials to assist physicians with billing. Specific objectives included:

• Ensure procedural fairness, impartiality, accountability and transparency in the new audit process
• Inform members about new billing education resources developed collaboratively between the OMA and Ministry of Health (MOH)
• Educate physicians about the new physician payment audit process
• Raise physician awareness about their rights and educational resources that support appropriate billing
• Increase physician engagement with these materials
• Revise the communications materials used by OHIP to when engaged in an audit
• Reduce claims payment errors

Terms of reference: post-payment accountability implementation steering committee

Background

The Plan to Build Ontario Together Act, 2019 was passed in December 2019 and includes legislative amendments to OHIP payment accountability, including amended Health Insurance Act provisions related to Ontario Health Insurance Plan (OHIP) payments to physicians.

The MOH and the OMA have committed to continuing to work together to implement specific accountability items. Through the PSC, the parties agreed to establish the Post-Payment Accountability Implementation Steering Committee for this purpose

Objective

The steering committee will establish joint MOH/OMA working groups and will provide ongoing guidance to each working group as required for the purposes of implementing the objectives identified below.

Each objective will be completed by the dates noted, and the steering committee will present all recommendations to PSC in February 2021.

1) Billing education – complete by end of January 2021 (Education and Prevention Committee)

• Determine the source of major billing difficulties and use this to develop educational material
• Identify eligible physicians and when they would participate
• Determine difference in education for new physicians vs. physicians in practice
• Develop online materials to improve physician education
• Develop education material on reading and applying the Schedule of Benefits (the schedule)
• Develop education material on the steps in the physician payment audit process to ensure accountability and procedural fairness
• Establish best practices for communicating with physicians on billing information
• Improve supports for billing inquiries

Long-term goals (recommendations for future work)

• Develop billing education modules by specialty
• Develop billing education for staff and billing agents
• Seek to link billing education to Continuing Medical Education (CME) credits
• Consider evaluation of effectiveness of education

2) Schedule clarifications – complete by end of January 2021 (Education and Prevention Committee)

• Identification and prioritization of potential clarifications by both MOH and OMA sections with a focus on items that may lead to payment concerns
• Clarification drafting
• Implementation communications
• Liaise with EPC to ensure any changes are reflected in educational material

Long-term goals (recommendations for future work)

• Major revision of the schedule and/or review alternative to the current schedule

3) Publishing payments – complete by end of January 2021 (Staff Communications Working Group)*

• Provide advice on the method and time frame to publicly report
• Provide advice on the necessary context to be provided in conjunction with release of payment information

4) Payment audit – complete by end of January 2021 (Staff Legal Working Group)

• Establish communication templates for entire profession and also individual doctors
• Policies and procedures for internal MOH fee-for-service audit processes including identification of potential billing concerns/audit focus, policies and procedures for on-site review, and general audit process communications

5) Other – complete by end of January 2021

• Develop recommendations on length of time for claims submission, including any mitigation strategies if there are changes
• Reduce administrative burden associated with rejected claims (such as newborn rejections)
• Address pre-payment issues
• Establish consistent parameters for claims review across OHIP claims offices

Long-term goals (recommendations for future work)

• Certify third-party billing software

The steering committee will bring forward joint recommendations to the PSC for endorsement prior to implementation. All recommendations will support the implementation of amended audit processes by May 2021.

If the steering committee is unable to develop a joint recommendation for any of the above noted items, the matter will be referred to the PSC.

Committee composition

The steering committee will be composed of two representatives from each party, with one representative from each party identified as the co-chair, plus appropriate technical support staff.

The parties may determine the makeup of working groups as is needed for the purposes of completing the objective items. The makeup of working groups may differ for each of the objective items and may change over time as work towards completion of each item evolves.

The parties will be responsible for expenses related to their own representatives and staff.

Administrative support for the purposes of meeting scheduling and coordination will be provided by the MOH.

The steering committee may consult with outside parties and experts to support the completion of objectives.

Committee mandate

• Determine scope of work related to PPA
• Assign work to sub committees and/or staff
• Review and approve workplans and timelines
• Provide oversight of work
• Resolve conflicts in recommendations, if possible
• Make recommendations related to long-term goals

Timing and reporting

The steering committee will work with each working group to develop a workplan(s), including prioritization of objective items and target timelines, and will present the workplan to PSC for endorsement.

The steering committee will meet monthly or as required to hear and address matters that require the attention of the committee. Meetings may be established at the request of either co-chair or at the request of working groups through their respective co-chair.

Meetings may be held in person or by teleconference/videoconference as deemed appropriate by the co-chairs.

The steering committee will provide regular status updates on the progress of work and will present recommendations to the PSC as needed or as requested by the PSC.

* The Publishing Payments working group was subsequently put into abeyance as the ministry indicated there is currently no timeline to proceed with publishing payments in the near future. The ministry will advise if this changes, and the group will resume its work.