Quebec’s health insurance board has the power to investigate clinics

CBC News

Over the course of two years, the number of inspections Quebec’s health insurance board (RAMQ) has done at medical clinics dropped by half, according to documents obtained by Radio-Canada.

The check-ups help uncover whether private clinics are charging illegal fees to patients, among other things.

In 2015, the RAMQ did 298 inspections and found that 35 clinics were charging patients for services that are covered by the public health insurance plan. In 2017, only 150 inspections were done; 12 clinics were found to be charging illegal fees.

A law passed in 2016 gave teeth to the RAMQ’s inspectors — before, inspections were more preventive in nature. Inspectors weren’t able to invoke laws and dole out fines.

In an email, a spokesperson for the RAMQ explained that the new powers bestowed upon the board’s 25 inspectors makes the inspection process more complicated, notably because they increased the standard of proof needed to write up lawbreakers.

The spokesperson also said the inspectors’ work was delayed last year due to the passing of a new law that forbids doctors from charging certain fees to patients. Staff had to undergo training in order to be able to apply it properly.

Worrisome drop, says watchdog

Dr. Isabelle Leblanc heads a group of Quebec doctors and medical students who work to preserve the universal nature of Quebec’s health care system.

She says the drop in inspections is cause for concern because it’s up to the RAMQ to make sure that doctors are following the rules.

“Inspections that aren’t based on complaints, just going to check out what’s going on in the clinics, are important because we know that due to the power imbalance, there are many patients who don’t want to file a complaint against their doctors,” she said.
Leblanc questioned whether the government made sure the RAMQ had the necessary resources to carry out inspections and investigations when it decided to increase their powers.

Opioid addiction costs employers $2.6B a year for care (U.S.)

A new report shows large employers spent $2.6 billion to treat opioid addiction and overdoses in 2016, an eightfold increase since 2004. More than half went to treat employees’ children.

The analysis released Thursday, April 5, 2018 by the nonpartisan Kaiser Family Foundation finds such spending cost companies and workers about $26 per enrollee in 2016.

Employers have been limiting insurance coverage of opioids because of concerns about addiction. The report finds spending on opioid prescriptions falling 27 per cent from a peak in 2009.

Researchers analyzed insurance claims from employers with more than 1,000 workers. Most are self-insured, meaning they assume the financial risk.

Workers share the costs. Steve Wojcik of the National Business Group on Health says for every $5 increase, employers typically cover $4 and pass $1 to workers.

Health care providers billing ‘impossible’ hours treating car crash victims

Hundreds of health-care providers in Ontario are billing insurance companies for an improbable number of daily hours spent treating car crash victims, recent insider data suggest.

However, no one appears to be leading a charge against the potentially fraudulent overbilling worth millions of dollars a year, leaving it to drivers to pick up the tab in the form of higher insurance premiums.

“Right now, it’s a shared problem between the industry, individual insurers, the colleges that oversee these different types of practitioners…and then the government,” said Ben Kosic, CEO of the Canatics insurance consortium. “It isn’t clear that any one party holds either the keys to the solution or the responsibility.”

The closely held data obtained by The Canadian Press suggest some chiropractors, physiotherapists, psychologists, massage therapists or other providers are billing for an excessive number of hours _ frequently averaging more than 24 hours per day.

The so-called “impossible day” data are drawn from the mandatory clearing system known as Health Claims for Auto Insurance or HCAI. Health-care providers are required to submit claims forms electronically through HCAI to bill auto insurance companies directly for treatment of patients and clients.

Canadian Insurance Crime Services, better known as Canatics and whose mandate is to fight insurance crime, has in the past year been quietly using massaged HCAI data in an effort to identify individual high billers, something not previously possible on a wide scale.

Canatics, which comprises nine insurance companies owning about 75 per cent of the auto-insurance market in Ontario, identified at least 700 “suspicious” billers through the new process.

“Clearly, when there are multiple days across a year where a provider appears to be overbilling, that is a good trigger to do a more thorough investigation,” Kosic said. “These are not in and of itself proof that anybody is doing anything fraudulent but it’s certainly a good trigger to launch a more formal investigation, where the forms can be pulled and the details of those forms can be investigated.”

That, however, is where the system is breaking down _ in part due to its complexity and multiple moving parts.

The Canatics data exclude 25 per cent of the insurance market, and sharing fraud-related information across the industry is piecemeal at best, insiders say. Good faith provisions generally mean paying out first and disputing later, but investigating suspicious billers _ and proving any fraud _ is costly and time-consuming.

“The industry needs the help of the government and the colleges to actually remove these guys from the system: somehow shut the clinics down or remove their licences, or support the industry in taking these guys to court, which is always very difficult,” Kosic said. “There are different tools that could be used to fight this problem but there is no co-ordinated plan right now.”

The upshot is that insurance companies have been passing on overbilling costs to all drivers in the form of higher premiums, undermining successive government and industry promises to give motorists a break.

The Financial Services Commission of Ontario, which regulates the insurance industry and has the power to fine or take other action against scoff-laws, has reported an “unacceptable” 70 per cent of providers were in violation of various rules in 2016-2017 _ an improvement from the 85 per cent non-compliance reported a year earlier. Violations included submitting unsigned claims forms or failing to verify patient identities. Prosecutions, however, are rare.

A spokeswoman said the commission will conduct a “thorough” investigation where it has evidence of non-compliance, and encourages consumers, the industry and those providing health services to report suspected fraud.

The Ontario government, which did not respond to questions, is in the process of setting up a Serious Fraud Office although it remains to be seen how much of its attention will be devoted to auto insurance. The Insurance Bureau of Canada, which speaks for most of the industry, said the office should help _ once it’s up and running.

“There is an enforcement issue as well,” said bureau spokesman Steve Kee. “It is vital that there must be co-operation between the regulator, insurers, the regulatory colleges, and the (Serious Fraud Office).”

Colleges, which regulate the various health-care professions, say members must adhere to rules and guidelines around billing.

“If you are aware of any inappropriate behaviour, I encourage you to bring it to the attention of the college,” said Jo-Ann Willson, registrar of the College of Chiropractors of Ontario. “If there is HCAI information about chiropractors, please feel free to forward that to us for review.”

For now, Canatics is waiting to see whether member insurance companies investigate based on its high-biller information and what they might find. Such reviews would help determine how accurate the data are in identifying fraud, perhaps leading to more effective policing of the system, and, theoretically, to lower premiums for drivers.

Manitoba government cuts medicare coverage for international students

The Manitoba government is eliminating medicare coverage for international students.

A regulatory change approved by the Progressive Conservative cabinet means international students will now have to buy private health insurance while studying in Manitoba.

Finance Minister Cameron Friesen said earlier this month the government was considering the move, and added that some other provinces also don’t cover international students.

The health coverage was instituted by the former NDP government in 2012 and it costs the province about $3 million a year.

The Canadian Federation of Students said the cut will put students’ health at risk.

The group also says international students already pay a lot to attend schools in Manitoba.

“International students pay three to four times in tuition compared to a domestic student,” the federation said in a written statement.

“The (Brian) Pallister government did not consult any major stakeholders _ namely international students or student associations _ in their deliberations to revoke a basic right.”

OmbudService for Life & Health Insurance reports on record numbers

 Canada’s OmbudService for Life & Health Insurance (OLHI) held its annual general meeting and released its annual report for 2016/17, reporting on a year of record numbers and renewed priorities.


  • Complaint volumes increase by 23.2% across Canada, marking a historic high
  • Increase in complaints from Quebec (+36.2%), Prairie provinces (+25.6%) and British Columbia (+ 24.4%)
  • Public contacts exceed 87,000
  • Edmonton office established as a part of western expansion strategy

“We discovered many things about ourselves this past year: we are small yet influential; we are experts in our field; we are strategic; and we are ready to redefine our future,” said Chair Dr. Janice MacKinnon at the meeting on September 14, 2017. “The launch of OLHI’s new case management and reporting system (CMRS) and website provides us with an opportunity to take a fresh look at how we do business today and moving forward.”

Among OLHI’s business plans for the future is increasing visibility outside Central Canada. This past year, complaint volumes rose in ManitobaSaskatchewanAlberta and British Columbia. To build on this momentum, OLHI established a physical presence in Edmonton in Q4 with a new office.

For fiscal 2016/17, OLHI received 2,632 complaints, with 57.5% of these relating to denied claims. Disability, life and employee healthcare & dental, together, made up 83.9% of all product complaints. Web visits rose by 19.1% over last year, reaching nearly 85,000.

“OLHI is successful because of stakeholder support and the respect we receive as an independent, impartial organization,” said Brigitte Kent, Acting Executive Director. “This allows us to meet our benchmark of closing 80% of all complaints within 120 days.”

Looking ahead, OLHI will continue to measure effectiveness and efficiency, identifying best ways to utilize the CMRS and accelerate service without sacrificing quality. OLHI will also complete its third Independent Review and begin work on ensuing recommendations.

For more detail on OLHI’s operations, including case studies and statistics, the full 2016/2017 Annual Report is available at

About the OmbudService for Life & Health Insurance
The OmbudService for Life & Health Insurance (OLHI) is Canada’s only independent complaint resolution service for consumers of Canadian life and health insurance. Canadians trust OLHI to review their insurance complaints about life, disability, employee health benefits, travel, and insurance investment products such as annuities and segregated funds. OLHI’s free bilingual services are available to any consumer whose insurance company is an OLHI member – and, currently, 99% of Canadian life and health insurers are. OLHI also offers general information online about life and health insurance. To ensure impartiality, OLHI’s operations are overseen by the Canadian Council of Insurance Regulators (CCIR). For more information, visit

SOURCE OmbudService for Life & Health Insurance

Desjardins Insurance announces changes to its leadership team

Press Release:

Gregory Chrispin, Senior Executive Vice-President of Wealth Management and Life and Health Insurance, is pleased to announce the following appointments.

André Langlois has been named Senior Executive Vice-President, Life and Health Insurance.

André will head up operations for Desjardins Insurance and all of its business lines, including: individual insurance, group and business insurance, group retirement savings and creditor and direct insurance. He will be responsible for managing the group savings firm Desjardins Financial Security Investments (DFSI) and the SFL and Desjardins Financial Security Independent Network (DFSIN) distribution networks. André has extensive knowledge of the life and health insurance sector, acquired over nearly 30 years with Desjardins Group.

Michael Rogers has been named Vice-President, Sales and Distribution.

In this national role, Michael will be responsible for individual insurance business development. He will also manage the SFL and DFSIN distribution networks and the group savings firm Desjardins Financial Security Investments, which has more than $14 billion in assets. Michael will be rolling out a renewed service offer for our distribution partners to contribute to their performance and strengthen their presence across the country. Relying on the expertise of 4,800 people and more than 10,000 distribution partners, Desjardins Insurance provides peace of mind to more than 5 million Canadians. With assets of $100.3 billion, the company is the fifth largest life and health insurance company in Canada.


John Bordignon
Media Relations – State Farm Canada

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