The Ontario Auditor-General’s recent report and news coverage have highlighted physician billing practices across the province, revealing gaps in Ministry oversight and patterns that could warrant scrutiny. For Ontario physicians, understanding audit triggers and implementing preventive measures are essential to protecting your practice’s financial health and professional reputation.
What Could Trigger an Audit by the Ontario Ministry of Health?
The Ministry’s Provider Audit Unit actively identifies billing concerns through several channels:
Tips and complaints from the public, healthcare employees, or other physicians remain the primary audit trigger. The Auditor-General’s report highlighted extreme cases: 82 doctors reported working 24+ hours in a single day, a diagnostic radiologist billed for 461 patients per day, and an ophthalmologist billed $6.7 million annually—double the next-highest biller in the specialty.
Billing pattern anomalies, including unusually high claim volumes, services inconsistent with typical practice patterns, billing multiple codes for a single episode, or billing complex services when simpler services appear appropriate, all raise red flags.
Billing Practices That May Warrant Closer Review
Not all billing errors lead to audits. Routine claim rejections — such as invalid health card numbers or missing information — are generally administrative issues and do not, on their own, trigger Ministry audits. However, certain billing practices may draw scrutiny when they reflect patterns outside typical Ministry expectations. Common examples include:
- Excessive use of certain fee codes: High volumes of specific, high-value, or time-based codes that are inconsistent with peer practice patterns.
- Multiple visit or service codes for a single encounter: Billing more than one visit code, or multiple services that should be billed as part of a single episode of care.
- Misuse of fee codes: Selecting codes that do not accurately reflect the service provided, its complexity, or the care setting.
- Service unbundling: Separately billing components that are intended to be claimed under a single comprehensive code.
- Insufficient supporting documentation: Inadequate charting for complex or time-based services, even when the code itself is appropriate.
Breaking Down Common Billing Considerations by Specialty
Family Practitioners encounter frequent challenges with:
- Rostering and enrolment codes: Patients should be rostered based on the date the enrolment form is signed. Backdating or mass-enrolling patients on a single date does not align with Ministry rules.
- After-hours and on-call premiums (including Q012): These codes should only be billed when all timing and eligibility requirements are met, including after-hours thresholds and on-call criteria.
Hospital-Based Physicians and Specialists often face challenges with:
- Service location and master number usage: Accurate use of the correct hospital master number is essential, particularly for physicians working across multiple sites.
- Counselling codes: Counselling codes require the minimum time threshold (typically 20 minutes) and clear documentation of start and end times in the chart.
- Documentation to support billed services: The medical record must clearly support the level and type of service claimed.
Check out our blog: Commonly Missed OHIP Q-Codes Every Physician Should Know and our Hospital Billing Codes Quick Reference Guide for more information on how to avoid some of these challenges.
Ophthalmology ranks among the highest error-prone specialties:
- Complex procedure coding for cataract surgeries and retinal procedures
- Modifier usage errors, especially laterality codes (LT/RT)
- Bundled procedure issues
- Varying payer documentation requirements
Diagnostic Radiology faces unique challenges:
- High-volume billing patterns that may appear suspicious even when legitimate
- Complex interpretation codes
- Service frequency issues with multiple imaging studies
What to Do If You Are Audited
If notified of an audit:
Respond promptly. The Ministry allows time to provide medical records and explanations. Reviews typically take three to six months.
Organize documentation. Ensure medical records, operative notes, and supporting documentation are complete and accessible.
Seek expert guidance. Consult billing specialists or legal counsel experienced with OHIP audits.
Review billing practices. Use the audit to identify and correct systematic issues.
Please refer to Ministry resources for more information on the audit process.
How DoctorCare Can Help
DoctorCare’s billing management solutions help Ontario physicians clearly understand the eligibility criteria and documentation requirements behind each OHIP billing code. Our team works closely with physicians to coach and encourage billing that is both appropriate and optimized—helping them bill with confidence, knowing their claims are consistent, well-documented, and aligned with Ministry expectations.
Our team supports you through:
Complete billing audits: Thorough reviews identify challenge areas and improvement opportunities from day one, catching issues before they trigger Ministry attention.
Automated error correction: Our Billing Care solution reviews and submits claims while automatically fixing and resubmitting errors. Works with OSCAR Pro, Accuro, Telus, and other popular EMR platforms.
Real-time insights: Our secure Physician Portal provides full visibility into billing performance, including corrected errors, premiums, and incentive payments, in one location.
Proactive audit protection: Regular reviews by billing experts identify potential red flags early. DoctorCare stays current with all 5,000+ OHIP codes and evolving rules.
Expert support: Experienced billing specialists provide ongoing guidance through Ontario’s complex billing landscape.
Conclusion
With the Auditor-General highlighting both aggressive billing patterns and systemic oversight challenges, professional billing support is essential protection. DoctorCare’s track record of correcting hundreds of thousands of errors and recovering lost revenue makes us an invaluable partner in maintaining compliance while maximizing legitimate reimbursement.
Don’t wait for an audit notice. Get started with a free billing assessment from DoctorCare to protect your practice while you focus on excellent patient care.
