Health

Reports about doctors double-billing aren’t telling the full story

By AdvocateDaily.com Staff

Media reports highlighting complaints from patients and advocacy groups about physician double-billing are “misleading and alarmist,” says Toronto health lawyer Tracey Tremayne-Lloyd.

“The portrayal of these situations as double-billing is a misrepresentation of fact,” she tells AdvocateDaily.com.

“Though there are likely some outliers, the vast majority of the medical profession understand and abide by the legal and ethical billing rules that govern them.”

Tremayne-Lloyd, principal of TTL Health Law, comments on a series of articles that chronicled complaints from patients about doctors who work both in the public system but also charge extra fees to provide quicker access to health care in private clinics.

She says the reports simply don’t tell the whole story.

According to one article, patient records, court filings and government audits suggest that some doctors are directing patients to private clinics where those same physicians have a stake in the profits and are routinely double-billing, where they charge both the patient and the government for different aspects of the same treatment. The article notes the “situation is particularly acute in B.C., where there are now dozens of private medical facilities.”

Tremayne-Lloyd says these British Columbia private facilities, offering timely, accessible care, seem to have thrived by public demand because people are tired of suffering for years waiting their turn in the publicly funded system.

She says any Canadian citizen can go across the border to the United States and pay for health care from their own after-tax income.

"Many do this because these privately run surgical units are not common in Canada," Tremayne-Lloyd says.

"By getting their care in the U.S. with their own money, Canadians have to leave their own province and their family behind to get the care they need and want in a foreign country. They are also taking their money out of our economy and spending it in the U.S."

But Tremayne-Lloyd says you would probably not find in Ontario a surgical facility where medically necessary, insured (by the province) procedures are being performed.

“It’s not happening. My information is these clinics don’t exist," she says.

“What I believe does exist are facilities where patients can access private medical services that are either not insured by the province or new, innovative treatments that have not yet found their way into the government fee schedule."

One such example is laser vein surgery, which isn't covered by the Ontario government, but is offered at private clinics in Ontario, Tremayne-Lloyd explains.

"Vein surgery is sometimes medically necessary, but the method of doing it in a clinic using lasers isn't covered by the province," she says. "You won't find laser vein surgery in the fee schedule."

Tremayne-Lloyd says physicians are letting their patients know that less-invasive procedures are available at private clinics so they are aware of the options. In such circumstances, patients have the right to exercise their own choice to wait and obtain the procedure in the public system when accessible or pay out-of-pocket to receive the treatment in a privately run centre with state-of-the-art equipment and innovative techniques, she adds.

“Obtaining informed consent is a legal duty for physicians and in order to get informed consent, physicians have a duty to tell the patient everything about the risks and other treatment options," she says.

Tremayne-Lloyd says there are also private dermatology clinics that offer procedures that are considered medically necessary but not insured by the government plan.

Doctors who provide care in both the public system for insured services and at private clinics for uninsured services, such as a laser vein procedure, aren't double-billing or in a conflict of interest, she says. They are simply providing a service that patients wish to have, she says.

If they were charging the province and the patient for the same service, that would be considered double-billing, she adds.

Tremayne-Lloyd says there are two key pieces of legislation related to the topic of doctor billing: the federal Canada Health Act, which requires that every citizen has access to publicly funded, timely, accessible health care; and the provincial Health Insurance Act, which sets out how each province is the exclusive insurer for medically necessary services.

“The provinces must ensure that physicians are prohibited from charging any money over and above the fee that the provincial insurer pays to doctors for that service,” she says.

"If there are any physicians charging patients for medically necessary health care, the provinces are supposed to self-report to the feds how much was billed and Ottawa will deduct that from its transfer payment. There is a significant incentive for every province to strictly enforce those rules.”

The problem that has developed over time, she says, is the demand for medically necessary health care far exceeds health budgets. The resulting wait lists for non-emergency surgeries prioritize those who need the procedures, but it means some people have to wait months — or longer — for procedures such as a hip or knee replacement, or cataract surgery, Tremayne-Lloyd adds.

The operating room time and staff simply aren’t available to handle all of the cases in the system, she says.

But if some physicians wanted to establish, with their own funds, a private clinic with an operating suite to handle the patients on the wait lists for medically necessary procedures and bill the province for those procedures, the law prohibits them from charging even the overhead costs of the facility and the staff required to perform the surgery, Tremayne-Lloyd says.

"While there may be the odd physician who is offside and behaving badly, the suggestion that doctors are routinely and illegally double-billing is alarming and misleading," she says.

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