4 total
Physician's billing of fee code K070 for modifying home care medical orders did not constitute misrepresentation.
The General Manager of OHIP alleged that the applicant physician misrepresented the nature of services by billing fee code K070 multiple times for the same patient when modifying home care medical orders.
The applicant appealed to the Physician Payment Review Board, arguing his billing practice was consistent with the Schedule of Benefits.
The Board found that the wording of fee code K070 does not expressly limit its use to the initial home care application.
The Board concluded that the applicant's practice of billing K070 when submitting a fresh home care services request form to modify medical orders was a reasonable interpretation and did not constitute misrepresentation under s. 18(2) of the Health Insurance Act.
Motion to dismiss for lack of jurisdiction denied; dispute over fee code interpretation falls within Board's jurisdiction.
The General Manager of OHIP brought a motion to dismiss a physician's appeal for lack of jurisdiction, arguing the decision to demand repayment was made under s. 37.1(7) of the Health Insurance Act due to an absence of records, which is subject only to judicial review.
The physician argued the dispute concerned the interpretation of a fee code, granting the Physician Payment Review Board jurisdiction under s. 18.
The Board dismissed the motion, finding that the essential character of the dispute concerned the interpretation of a fee code, and that the General Manager's correspondence satisfied the notice requirements of s. 18.
The Board concluded it had jurisdiction to hear the appeal.
Application for judicial review dismissed; OHIP authorized to impose $150 administrative charge per unauthorized payment.
The applicant physician sought judicial review of a decision by the General Manager of OHIP imposing an administrative charge of $81,450 for 543 unauthorized payments.
The Divisional Court dismissed the application, finding that the General Manager had no duty to refer the administrative charge issue to the Health Services Appeal and Review Board, as the Board's jurisdiction is limited to reviewing unauthorized payments.
The Court confirmed the General Manager's authority to impose a $150 administrative charge for each unauthorized payment under the Commitment to the Future of Medicare Act, 2004.
Furthermore, the Court noted it would have declined to grant the discretionary remedy of judicial review due to the applicant's delay in bringing the application.
Applicant participating in W.C.B. rehabilitation program is not employed for the purpose of statutory accident benefits.
The Applicant was injured in a motor vehicle accident while participating in a W.C.B. vocational rehabilitation program and receiving a temporary supplement to a permanent partial disability award.
He applied for statutory accident benefits, claiming entitlement to weekly income benefits under section 12(1) of the Schedule.
The Insurer paid benefits under section 13(1) (Benefit if No Income).
The Arbitrator found that the Applicant was neither employed nor self-employed while participating in the rehabilitation program, and that the W.C.B. supplement was not income from occupation or employment.
The Applicant's entitlement to weekly benefits was therefore correctly determined under section 13(1).
