MOHLTC Audit Review ProcessPayment Accountability Unit

Presentation to Independent Diagnostic Clinics Association

September 25, 2015Health Services Branch

Negotiations and Accountability Management Division

AGENDA

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SLIDE NUMBERS

2. AGENDA3. OVERVIEW4. MANDATE5. RESOURCES6. CURRENT REVIEW STREAMS7. REVIEW PROCESS8. REVIEW ANALYSIS9. REFERRAL MANAGEMENT10.SELECTED EDUCATION LETTERS11.IMPROVING ACCESS12.RESOURCE AND CONTACT INFORMATION

Payment Accountability and Stakeholder Services (PASS) is comprised of two program areas: Payment Accountability and Payment Programs and Partnerships. Payment Accountability provides stewardship and accountability controls for MOHLTC funded programs.

OVERVIEW

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Health Services Branch

Eligibility Programs

Provider Policy and Program

Design

Provider Facility Payment Unit

Payment Accountability

and Stakeholder Services Unit

Payment Accountability

Payment Programs and Partnerships

Payment Accountability’s mandate is to perform post-payment reviews of selected Health Services Branch (HSB) funded programs.

MANDATE

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Perform post-payment reviews of selected Health Services Branch (HSB) funded programs to ensure accountability for use of funds through adherence to payment requirements stated in the Health Insurance Act; Regulation 552; the Schedules of Benefits for Physician, Dental and Optometry Services; Independent Health Facilities Act; Physiotherapy agreements and other supporting agreements within HSB.

RESOURCES

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Payment Accountability

Senior Manager

Senior Program

Consultant

Lead Medical Advisor

ClerkReview Officer

Program Analyst

Program Manager

Family Medicine Radiology General

Surgery Anesthesia

The Payment Accountability unit is composed of a diverse pool of expertise who are accountable for undertaking proactive and reactive reviews of selected Health Services Branch funded programs to ensure appropriate stewardship of public funds.

Payment reviews include payments for fee-for-services providers, dental and optometry services, physiotherapy, and independent health facilities.

FFS PROVIDERS

Post payment review of issues reported by

internal and external sources relating to fee for service issues, e.g., fee

code eligibility.

30,000+ Providers

$7.8 B¹

PHYSIOTHERAPY PROVIDERS

Post payment review of issues reported by the

Physiotherapy Program area relating to

compliance with Transfer Payment Agreement and

funding requirements, e.g., referral standards.

200+ Contracts

$250 M

IHF PROVIDERS

Post payment reviews of IHF related technical fees and ambulatory contracts.

900+ IHF Licensees

> $400 M²

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¹ The largest component of IHF related expenditures. ² Does not include professional fee expenditures.

CURRENT REVIEW STREAMS

Payment Accountability’s post-payment review process includes both reactive and province-wide reviews.

REVIEW REQUESTS

RequestsOriginating From HSB & External Sources

INDIVIDUAL OR SYSTEM LEVEL INTERVENTIONS PERFORMANCE

INDICATORS

Reactive ReviewsInitiate a Review of

a FFS provider, IHF Group, or Physiotherapy

Clinic

Provincial Projects Focus on

Prioritized Payment Topics for a Province Wide Review

POTENTIAL ACTION(S)

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CPSO: College of Physicians and Surgeons of Ontario, CFMA: Commitment to the Future of Medicare Act, RMFC: Risk Management and Fraud Control, PPRB: Physician Payment Review Board

REVIEW PROCESS

Issues and Complaints Specific to Individuals

Topic Submissions for Provincial Review

Outcomes

• Recovery of Payments

• Referral: CPSO, CFMA, RMFC

• FFS Education Program

• Review Tribunals: PPRB, Practitioner Review Committees

Payment Accountability uses available databases and records to conduct analyses on stakeholders to thoroughly address the identified issues.

Review Analysis

Conduct Billing

Analysis

Records Review

Extract Claims

History Data

Request Additional

Information

REVIEW ANALYSIS

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Referral Triage & Disposition

Triage & Disposit

ion

Medical Advisor

Allied Health Advisor

External Medical

Specialist

Resolve

Redirect

Program

Analyst

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REFERRAL MANAGEMENT

• Rapid identification of higher risk profile and time sensitive referrals.

• Rapid identification of cases which should be immediately redirected or resolved.

• Minimization of delays associated with sequential processing and rework.

• Matching complexity/level of review with reviewer expertise.

• Standardization of methodology, thresholds and communications with processing referrals.

• Case management continuity/consistency.

Selected Education Letters: A proactive stakeholder engagement strategy¹

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¹SEL recipients are physicians and IHF licensees who bill the schedule codes being addressed.

TopicSOB

Code(s)Date of Mailout #MDs #IHFs

J149: Ultrasound guidance of biopsy, aspiration, amniocentesis or drainage procedures

J149 24-Aug-15 1311 ×

A335/A365 Radiologist consultsA335/A365

24-Aug-15 644 ×

J149: Ultrasound guidance of biopsy, aspiration, amniocentesis or drainage procedures

J149 17-Sept-15 × 212

Are there information gaps which could be addressed through this communication process?

SELECTED EDUCATION LETTERS

Expedited and Episode of Care (EOC) Focused Review Cycle of Physiotherapy Providers

Data Refresh

Providers Above

Threshold

Records Request

Focused Review

EOC Recovery

Notice

Key objective is to reinvest recovered EOCs within fiscal year to improve access and patient care.

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IMPROVING ACCESS

Physician Schedule of Benefits www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html

IHF Website www.health.gov.on.ca/en/public/programs/ihf

Payment Accountability Unit Phone: Jeff Hutchison (613)536-3111 eMail: Jeff.Hutchison@Ontario.ca

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RESOURCE AND CONTACT INFORMATION