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.
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.
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:
* 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 may be carried out by the RAMQ or by a designated third party for different reasons:
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.
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.
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.
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.
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.
For more information on the criteria to be taken into account on choosing a billing agency, do not hesitate to contact us.