Health fraud runs rampant


According to the OPP Health Fraud Investigations’ website [update April 2018- OPP website is not available anymore] , health fraud investigations are conducted in 3 areas of health care services:

  • Provider Fraud (physicians, pharmacists, optometrists) – fraudulent billings for medically unnecessary services or “bogus” services
  • User Fraud  – abuse and misuse of the health care system ( example: receiving health care services while using somebody else’s OHIP health card or illegally obtained health card)
  • Drug Diversion – black market trade in narcotics and other prescription medication

The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year (  I’m not aware of any current estimates for Ontario, but I suspect it is well over $300 million a year.
Recently Deb Matthews, in order to control health care costs and save $338 million, cut  fees for OHIP services.  If the Ministry of Health and Long Term Care (MOHLTC) was doing a better job in the accountability and fraud areas, none of these fee cuts would be necessary. Deb Matthews continues to penalize honest doctors;  fraudsters continue to claim “bogus” services to OHIP and OHIP pays.

It is good news though, that there are more and more people who are interested in finding out what  the MOHLTC actually does in order to identify and prevent fraudulent practices. They argue that the Ministry does not do enough, that the OHIP claim system lacks proper validation of submitted claims.

Take for example a request that was made to the MOHLTC  under the Freedom of Information and Protection of Privacy Act  and described in “Order PO-3105, Appeal PA11-235, MOHLTC, August 21, 2012”  
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The appellant made a request for access to information relating to the “Rules for determining the Validity and Eligibility of claims and the Medical Rules for the Assessment of OHIP claims.”  If the Ministry could provide the validation rules that they follow to detect ineligible or fraudulent claims, it would be easy to check if the Ministry really implemented these rules in the OHIP system.

There are too many scandals with accountability and lack of oversight in MOHLTC that cost Ontarians billions (eHealth, ORNGE, Diabetes Registry).  It is reasonable to ask what kind of mechanisms the Ministry have to prevent paying for fraudulent claims. Or does the Ministry just pay without any checking?

I was very entertained by the Ministry answer to the above request:

“ Medical rules for determining the validity and eligibility of claims are embedded in the OHIP medical claims processing system and are part of the application program code. They are not documented.”


Wow! Everything is in the program code. Is Ministry saying that there are no business requirements documents describing rules for validation of OHIP claims? Test plans are created from requirements documents…are there no test plans? Is there any testing done at all?

And here is more entertaining news from the Ministry.  Medical  Rules are not documented but there is a document with “computerized medical rules”:

“A document containing 1,363 pages that sets out the computerized medical rules of assessment of OHIP claims was located. Access to the document is being denied pursuant to sections 18(1)(c), (d) and 14(1)(i) of the Act.”


These answers from the Ministry don’t make sense. It seems to be that the Ministry does not want to admit that the OHIP claims system does not  validate claims, there is no accountability.  Ministry answer is “go fish”.

Some of the medical rules that the OHIP claims system should be using for validation can be found in the  Community Health Center Payment and Reporting Guide  or Billing Payment Guide for Blended Salary Model (BSM) Physicians.