According to the latest report on RAMQ (Québec Health Insurance Board) Checks conducted on health care professionals, the number of investigations and inspections, as well as the amounts due to the RAMQ are increasing year after year. The targets of these checks are physicians, optometrists, denturists, pharmacists and other members of the pharmaceutical industry and clinics.
However, more than half of the checks involve physicians.
The RAMQ’s role in the payment of physicians
In order to ensure sound management and compliance with its programs, the Québec Health Insurance Board applies several control measures to invoices from health care professionals and physicians.
If the RAMQ determines that a health care professional has violated an established law, it can recover the amounts collected in addition to applying administrative fees. Since 2017, RAMQ can also impose administrative monetary penalties (AMPs) on health care professionals who have received unauthorized amounts or benefits in violation of the Health Insurance Act (HIA) and the Act Respecting Prescription Drug Insurance.
Total number of checks conducted by the RAMQ
The data provided by the RAMQ shows a clear increase in the number of checks conducted in recent years, with the exception of 2020, in which its operations were, of course, disrupted by the COVID-19 pandemic.
As of October 2021, three types of checks are conducted:
- Administrative investigations
- Inspections
- Verifications
Total number of administrative investigations, inspections and audits conducted by RAMQ from 2016 to 2020 *
* It should be noted that the category of checks ‘Costs for which insured persons are billed’ no longer exists since 2020. The category of checks ‘Verifications,’ was added in 2020. The total number of checks includes these two categories.
Administrative investigations
Administrative investigations may be carried out by the RAMQ or by a designated third party for different reasons:
- A patient’s eligibility for programs managed by the RAMQ
- Costs for which insured persons are billed
- Payments to health care professionals
- For services that were not rendered, that were misrepresented or that were not covered
- On payments or refunds provided
Amounts owed to the RAMQ as a result of the investigations conducted over the past 5 years
In 2020, the amount owed to the RAMQ increased significantly compared to the previous year, to a total of $21,092,277. This sudden increase was due in large part to a pharmacy that sourced its drugs from an unrecognized wholesaler, owing $17,158,338 to the RAMQ. However, even without taking this exceptional case into account, the amounts owed as a result of investigations would have reached $3,933,939, which is almost double the amount of 2019.
Inspections
The RAMQ may conduct inspections in order to detect non-conformities regarding the invoices of health care professionals or clinics. In such cases, an inspector requests that the required documents be sent to him for their examination. He may also meet with the professionals at their workplaces.
The following table shows that there was an increase in the amounts due to the RAMQ year after year as a result of inspections until 2020. We are unaware of the reasons for the drastic reduction in 2020, but the administrative management of the pandemic may have played a role.
Amounts due to RAMQ following inspections from 2016 to 2020
Verifications
Each year, the RAMQ receives 55 million invoices from health care professionals, excluding pharmacists. Verifications allow the RAMQ to identify situations involving risks of error, non-compliance, fraud or abuse. They are carried out by a computerized system or by a RAMQ employee.
Responsibility of health care professionals and physicians
Health care professionals are responsible for their invoices at all times, even if they use the services of a billing agency. It is thus important to choose an agency with significant expertise in the field and that specializes in your practice.
Health care professionals must properly document patient records and follow the recommendations of their professional association and/or College of Physicians. A well-documented and complete record is required to confirm the services rendered. If a record submitted to the RAMQ is incomplete, the payment for the service rendered by the professional could be called into question.
Physicians must fully understand their payment agreement and issue their invoices in accordance with RAMQ regulations. They must thus make sure to use the correct act codes in their invoices to avoid any errors.
Choosing the right RAMQ billing agency
There are several RAMQ billing agencies in Québec. However, not all of them follow the same processes or offer the same tools for verifying invoices. In order to limit the risk of undergoing checks and being denied payment, we advise doctors to make a list of their needs and questions to ask the agency.
- How does the agency reduce the time you spend issuing invoices?
- What does the agency do to reduce the risk of invoicing errors?
- How much visibility does the agency provide with regard to your invoices?
- Do you have access to your invoices at all times?
- What expertise does the service have in your field?
For more information on the criteria to be taken into account on choosing a billing agency, do not hesitate to contact us.
