12-PPR-0004
PHYSICIAN PAYMENT REVIEW BOARD
PRESENT:
Ms. Jacqueline Gumienny, Designated Panel Chair
Dr. Samir Gupta, MD, Member
Dr. David Bridgeo, MD, Member
Dr. Ian Hector, MD, Member
Heard February 26th and 27th, 2013 at Toronto, Ontario
IN THE MATTER OF A REQUEST FOR HEARING under Section 18.3 of the Health
Insurance Act, Revised Statutes of Ontario, 1990, Chapter H.6., as amended.
B E T W E E N:
DR. PERRY VINCENT MAYER
Applicant
And
THE GENERAL MANAGER,
ONTARIO HEALTH INSURANCE PLAN
Respondent
Appearances:
For the Applicant: Dr. Perry Mayer, applicant
Mr. C. Jeffrey Freedlander, counsel
Mr. H. Michael Rosenberg, counsel
For the Respondent: Ms. Kristin Smith, counsel
DECISION AND REASONS
I. DECISION
This matter was brought by the applicant, Dr. Perry Mayer, following the receipt of a notice under the Health Insurance Act (“HIA” or the “Act”) that the General Manager of the Ontario Health Insurance Plan (“OHIP”) was of the opinion that the applicant was misrepresenting the use of fee code K070 of the Schedule of Benefits for Physician Services under the HIA (“Schedule of Benefits”).
The applicant seeks an order from the Physician Payment Review Board (“Board”) that confirms his practice of billing fee code K070. In addition, the applicant seeks an order that confirms that he did not misrepresent the nature of the services in billing fee code K070 in the circumstances of this appeal.
The respondent asks that the Board confirms OHIP’s opinion concerning fee code K070, and directs Dr. Mayer to use fee code K070 only for the first referral for admission of a patient to a home care program, with such order applying retroactively to July 19, 2012 (the date of the respondent’s notice under s. 18(15) of the HIA).
For the reasons that follow, the Board is not satisfied that the respondent has discharged its onus of proving that the nature of the services billed by the applicant were misrepresented either deliberately or inadvertently (as described under s. 18(2) of the HIA). The Board confirms that the applicant’s practice of billing fee code K070, when he determines that it is medically necessary to complete and submit a fresh home care services request form to modify his patient’s initial home care medical orders, is a reasonable interpretation of fee code K07