The Court affirmed, in part, an Order of the Respondent Committee requiring a physician to repay professional fees pursuant to the Saskatchewan Medical Care Insurance Act

24. January 2006 0

Administrative law – Physicians and surgeons – Billing matters – Judicial review – Procedural requirements and fairness – Natural justice – Failure to provide reasons – Evidence

Wong v. Joint Medical Professional Review Committee, [2005] S.J. No. 690, Saskatchewan Court of Queen’s Bench, November 15, 2005, Ball J.

The Appellant was a family physician who had been ordered by the Respondent Committee to repay professional fees in the sum of $22,826.82 pursuant to the Saskatchewan Medical Care Insurance Act, R.S.S. 1978, c. S-29 (the “Act”). At an earlier appeal, the Appellant had submitted that the Committee had failed to observe the rules of natural justice by failing to provide reasons for its reassessments and failing to consider the Appellant’s submission with respect to its proposed Order. The Committee provided supplementary reasons. In this appeal, the Appellant submitted that the Committee breached the rules of natural justice by basing its decision on information that was never disclosed to him and to which he had no opportunity to respond, and, second, that the Committee’s Order was not reasonably supported by the evidence.

The Committee’s Order reassessed fees billed by the Appellant in four categories. The first three were stated to be “due to misinterpretation of the billing code” and dealt with billings for health calls, nursing home patients, and patients receiving allergy injections. The fourth reassessed billings for “over-servicing” certain other patients. It required the Appellant to repay 20% of all billings attributable to “partial assessment or subsequent visit” for patients seen more than nine times, excluding nursing home patients and allergy patients. The fee reassessments “due to misinterpretation of the billing codes” in the first three categories were based on the Committee members’ understanding of the medical services provided and the proper interpretation of the billing codes. Their conclusions were supported in part by their professional expertise, in part by the statistical information presented to them, and in part by findings of credibility which they were in the best position to make. The Committee was entitled to deference from the Court in its determination of the percentage of billings to be converted to lower rates in each category. In the result, those determinations were not set aside.

The 20% fee reassessment for over-servicing resulted from the Appellant being reassessed for over-servicing patients in the other three categories. The 20% reduction for all fees billed for all patients in the fourth category was imposed without informing the Appellant of the evidence on which it was based and without giving him any meaningful opportunity to respond.

Section 49.2(10) of the Act required the Committee to adhere to the rules of natural justice, which entitled the Appellant to a fair hearing in which he is entitled to know the case against him and to be given a meaningful opportunity to respond. The Act gives the Committee a considerable amount of latitude in terms of the information upon which it may choose to act. Although the Committee has this discretion, once it decides to base its decision on certain evidence, it is required to give the Appellant a fair opportunity to respond to it. In this case, the Appellant was never informed of the facts on which the Committee intended to rely to support its reassessment of fees for over-servicing. This meant that he was given no opportunity to point out to the Committee that there was no discernible connection between the facts on which it relied and the Order it eventually made.

An Order of the Committee under section 49.2 of the Act must be reasonably supported by the evidence. The portion of the Committee’s Order related to over-servicing was not reasonably supported by the evidence.

As the matter had been ongoing for some three and one half years, involving voluminous materials and a lengthy hearing process, it would have been inequitable to refer the matter back to the Committee with directions to reconsider it anew. The Court affirmed the first three clauses of the reassessment Order and quashed the portion of the Order related to over-servicing.

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