Acts and Regulations

M-7 - Medical Services Payment Act

Section 5.5
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Review of billing patterns and recovery of overpayment
5.5(1)Notwithstanding any action taken by the provincial authority under section 5.4, the provincial authority may refer to the Professional Review Committee for review, and the committee shall review, patterns of billing of medical practitioners and oral and maxillofacial surgeons under the medical services plan in order to identify, in respect of a medical practitioner or an oral and maxillofacial surgeon,
(a) whether the quality of service provided was below a minimum acceptable level,
(b) whether the level of service provided was in excess of what could be considered to be medically required, and
(c) whether there has been misuse of the fee schedule under the medical services plan or under an agreement entered into under section 4.1,
and based on such review the committee shall make recommendations for action to the provincial authority.
5.5(2)Where, after conducting a review under subsection (1), the Professional Review Committee finds in respect of a medical practitioner or an oral and maxillofacial surgeon that the level of service was in excess of what could be considered to be medically required or that there has been misuse of the fee schedule, the Professional Review Committee shall, in addition to any other recommendation it may make to the provincial authority, recommend to the provincial authority an amount of overpayment to be recovered from the medical practitioner or the oral and maxillofacial surgeon, as the case may be, and may recommend the terms, conditions and schedule for the recovery of the overpayment.
5.5(3)Before the Professional Review Committee makes a recommendation to the provincial authority in respect of an action under this section, it shall provide the medical practitioner or oral and maxillofacial surgeon with an opportunity to make a representation to the committee respecting the matter under review.
5.5(4)The provincial authority shall recover from a medical practitioner or an oral and maxillofacial surgeon in respect of whom a recommendation for recovery of an overpayment has been made under subsection (2), the amount recommended for recovery by the Professional Review Committee and may deduct the amount of the overpayment from any payments that are or become payable to the medical practitioner or oral and maxillofacial surgeon, as the case may be, under the medical services plan.
5.5(5)Notwithstanding subsection (4), the provincial authority may, where it considers it appropriate to do so, recover less than the amount recommended for recovery by the Professional Review Committee or may recover the amount recommended on terms, conditions or schedule that is less onerous than that recommended by the Professional Review Committee, or both.
5.5(6)The provincial authority may, upon the recommendation of the Professional Review Committee,
(a) suspend any agreement entered into with a medical practitioner or an oral and maxillofacial surgeon for such period as it considers appropriate, or
(b) refuse to enter into any agreement with a medical practitioner or an oral and maxillofacial surgeon which would permit the medical practitioner or oral and maxillofacial surgeon, as the case may be, to practise his profession within the provisions of this Act and the regulations.
1996, c.49, s.3; 2003, c.20, s.12; 2019, c.12, s.20
Review of billing patterns and recovery of overpayment
5.5(1)Notwithstanding any action taken by the provincial authority under section 5.4, the provincial authority may refer to the Professional Review Committee for review, and the committee shall review, patterns of billing of medical practitioners and oral and maxillofacial surgeons under the medical services plan in order to identify, in respect of a medical practitioner or an oral and maxillofacial surgeon,
(a) whether the quality of service provided was below a minimum acceptable level,
(b) whether the level of service provided was in excess of what could be considered to be medically required, and
(c) whether there has been misuse of the fee schedule under the medical services plan or under an agreement entered into under section 4.1,
and based on such review the committee shall make recommendations for action to the provincial authority.
5.5(2)Where, after conducting a review under subsection (1), the Professional Review Committee finds in respect of a medical practitioner or an oral and maxillofacial surgeon that the level of service was in excess of what could be considered to be medically required or that there has been misuse of the fee schedule, the Professional Review Committee shall, in addition to any other recommendation it may make to the provincial authority, recommend to the provincial authority an amount of overpayment to be recovered from the medical practitioner or the oral and maxillofacial surgeon, as the case may be, and may recommend the terms, conditions and schedule for the recovery of the overpayment.
5.5(3)Before the Professional Review Committee makes a recommendation to the provincial authority in respect of an action under this section, it shall provide the medical practitioner or oral and maxillofacial surgeon with an opportunity to make a representation to the committee respecting the matter under review.
5.5(4)The provincial authority shall recover from a medical practitioner or an oral and maxillofacial surgeon in respect of whom a recommendation for recovery of an overpayment has been made under subsection (2), the amount recommended for recovery by the Professional Review Committee and may deduct the amount of the overpayment from any payments that are or become payable to the medical practitioner or oral and maxillofacial surgeon, as the case may be, under the medical services plan.
5.5(5)Notwithstanding subsection (4), the provincial authority may, where it considers it appropriate to do so, recover less than the amount recommended for recovery by the Professional Review Committee or may recover the amount recommended on terms, conditions or schedule that is less onerous than that recommended by the Professional Review Committee, or both.
5.5(6)The provincial authority may, upon the recommendation of the Professional Review Committee,
(a) suspend any agreement entered into with a medical practitioner or an oral and maxillofacial surgeon for such period as it considers appropriate, or
(b) refuse to enter into any agreement with a medical practitioner or an oral and maxillofacial surgeon which would permit the medical practitioner or oral and maxillofacial surgeon, as the case may be, to practise his profession within the provisions of this Act and the regulations.
1996, c.49, s.3; 2003, c.20, s.12