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OPINIONS / MEDICAL REVIEW COMMITTEE

My audit

'I have never been as emotionally traumatized by any process in my professional life'

One morning you receive a huge package marked "private and confidential" from the College of Physicians and Surgeons of Ontario. It states you have been referred by OHIP to the Medical Review Committee (MRC). Your heart falls to the floor and in a daze you wade through the reams of data they sent you: "Your volumes are twice the provincial average; your ratio of intermediate assessments to minor assessments is 30 to one as opposed to the provincial average of five to one; your recall rate is 33%, while the provincial average is 20%." On and on it goes with flat statistics.
In a daze you call the Canadian Medical Protective Association (CMPA). They are unemotional. A lawyer from a prestigious firm contacts you and instructs you to deal only through them. They walk you through the process.
They state you are fortunate; this is an expedited review. The auditors are only looking at two billing codes, namely A001 (minor assessment; it pays $17.30) and A007 (intermediate assessment; it pays $27.30). There will be no office inspection and you are only required to send down the 100 charts the MRC selected. You have to pick a date for the review, which will be conducted by a single physician member of the MRC.
You meet with your two lawyers—paid for by the CMPA. They review your charts and assess what they think. They feel your charts are above average: All services were performed but there may be some reduction from A007 to A001. This could entail a financial penalty. They feel that possibly 40% of your charts may have minor document insufficiency for which you will be docked 5% to 10% of the monetary value.
You send your charts to the MRC. They photocopy their "random" selection of visits they are auditing. The MRC's policy is that all visits must stand on their own in isolation to justify the bill submitted.
You meet with your two lawyers again for a dress rehearsal.
Your day arrives. This has been three months of absolute hell: Your sleep has been disrupted, you've lost weight; you've been irritable with patients and family; you have lost all interest in CME, patient care and any outside interests. All you can think about is what the auditor will ask and how can you justify your shorthand, a scrawled note, the things you take for granted and do not write down, all the negative findings you feel are understood and do not record in a busy practice.
But the day of the review is almost a relief. The MRC member is a kindly old retired doctor who is courteous in the extreme. He keeps saying things like: "You see a lot of people, don't you?" We spend the day going through 100 of my charts. The reviewer has a tick-off sheet in which he grades all my intermediate assessments. A few, he says, should have been minor assessments but for many you need to record more. You need to expand on the duration of symptoms, you need to state antibiotic dosage and duration, amount of narcotics given, etc.
The day ends; you are exhausted and emotionally spent. The MRC member was polite, friendly but firm. You stagger home and your lawyers say you did well; they are encouraging and feel your financial penalty may only be $20,000!
You start to put your life together. You stop needing tranquillizers to sleep. But still no day goes by without you thinking about this whole process.
You wait a further three months and finally the "direction" comes down. Results: 5% of the visits audited were deemed to have really been minor assessments instead of intermediate assessments (due to the small number these, they feel, can be ignored) and 57% of the visits audited were deemed to have "insufficient documentation." The visits were performed and deemed intermediate assessments but due to the documentation being not of a standard thought necessary, the "value of the service will be reduced by 5% on 52%" of my visits for the two-year period.
The direction is sent to my lawyer and myself. OHIP will assess the costs of the review to you—they charge interest from the last day of the period under review. At the time of writing arrangements are being made for OHIP to take back the money on a regular basis—plus interest, of course.
After six gruelling months the whole process is still not over. I have never been as emotionally traumatized by any process in my professional life. For the first time in 32 years, I've considered stopping practice. I've considered relocating. I've considered retiring. I've considered taking up another occupation.
I am left scarred. I do not view my practice and patients in the same light as before. Previous driving principles all pale before the necessity of keeping good charts to justify a bill.
The final dollar figure has yet to be relayed to me but the approximately $15,000 will never be justified by the anguish and disruption this very punitive process causes. There is no educational or remedial value to this process. This is an entirely arbitrary, discriminatory, demeaning and intimidating process all in the cause of a financial clawback and in an attempt to intimidate the profession to bill less and/or to accept an entirely ludicrously low per capita fee schedule.
I do not wish my name to be published as I am afraid they could come after me again. I feel this whole process should be changed to be more open and educational. No physician should have this kind of process hanging over their head.
—A Toronto doctor.

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