MOHLTC Audit Review Process Payment Accountability Unit Presentation to Independent Diagnostic Clinics Association September 25, 2015 Health Services Branch Negotiations and Accountability Management Division

AGENDA 2 SLIDE NUMBERS 2.AGENDA 3.OVERVIEW 4.MANDATE 5.RESOURCES 6.CURRENT REVIEW STREAMS 7.REVIEW PROCESS 8.REVIEW ANALYSIS 9.REFERRAL MANAGEMENT 10.SELECTED EDUCATION LETTERS 11.IMPROVING ACCESS 12.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 3 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 4 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 5 Payment Accountability Senior Manager Senior Program Consultant Lead Medical Advisor Clerk Review 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 Contracts $250 M IHF PROVIDERS Post payment reviews of IHF related technical fees and ambulatory contracts IHF Licensees > $400 M² 6 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 Requests Originating From HSB & External Sources INDIVIDUAL OR SYSTEM LEVEL INTERVENTIONS PERFORMANCE INDICATORS Reactive Reviews Initiate 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) 7 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 8

Referral Triage & Disposition Triage & Disposition Medical Advisor Allied Health Advisor External Medical Specialist ResolveRedirect Program Analyst 9 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 10 ¹SEL recipients are physicians and IHF licensees who bill the schedule codes being addressed. Topic SOB Code(s) Date of Mailout#MDs#IHFs J149: Ultrasound guidance of biopsy, aspiration, amniocentesis or drainage procedures J14924-Aug × A335/A365 Radiologist consults A335/ A Aug-15644× J149: Ultrasound guidance of biopsy, aspiration, amniocentesis or drainage procedures J14917-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. 11 IMPROVING ACCESS

Physician Schedule of Benefits IHF Website Payment Accountability Unit Phone: Jeff Hutchison (613) RESOURCE AND CONTACT INFORMATION