NLR 69/03 - Physicians and Fee Regulations under the Medical Care Insurance Act, 1999

NEWFOUNDLAND AND LABRADOR REGULATION 69/03 Physicians and Fee Regulations under the Medical Care Insurance Act, 1999 Amended by: 2014 cC-10.1 s70 NEWFOUNDLAND AND LABRADOR REGULATION 69/03 Physicians and Fee Regulations under the Medical Care Insurance Act, 1999 (Filed June 10, 2003) Under the authority of section 21 of the Medical Care Insurance Act, 1999 , I make the following regulations. Dated at St. Johns , June 9, 2003. Gerald Smith Minister of Health and Community Services REGULATIONS Analysis 1. Short title 2. Definitions 3. Provision of insured services outside the province 4. Fee payment to physician or beneficiary 5. Pattern of practice 6. Formula determining pattern of practice 7. Insured services received out of province 8. Application for payment of insured services 9. Assignment of payments 10. Disclosure 11. Charges against beneficiary 12. Debt due to minister 13. Delegation by minister 14. Medical Consultant's Committee 15. Composition of committee 16. Transitional 17. Repeal Short title 1. These regulations may be cited as the Physicians and Fee Regulations . 69/03 s1 Back to Top Definitions 2. In these regulations (a) "Act" means the Medical Care Insurance Act, 1999 ; (b) "beneficiary" means a person who meets the requirements to be a beneficiary in the Medical Care Insurance Beneficiaries and Inquiries Regulations ; (c) "committee" means the Medical Consultant's Committee referred to in section 14; (d) "department" means the department presided over by the minister; (e) "fee schedule" means (i) in relation to services carried out by physicians, the Medical Payment Schedule set by the minister, (ii) in relation to surgical-dental services carried out by dentists and anaesthetists, the Surgical-Dental Payment Schedule set by the minister; (f) "hospital" means a hospital as defined in the Hospitals Act ; (g) "illness" includes mental illness, sickness, injury, disability or complaint; (h) "insured services" has the meaning assigned to that term by the Medical Care Insurance Insured Services Regulations; (i) "minister" means the minister appointed under the Executive Council Act to administer the Medical Care Insurance Act, 1999 ; and (j) "physician" includes a person entitled to provide an insured service. 69/03 s2 Back to Top Provision of insured services outside the province 3. (1) A person lawfully entitled to practise medicine in the place in which that practice is carried on by him or her shall be entitled to provide insured services to beneficiaries outside the province. (2) A person lawfully entitled to practise dentistry in the place where that practice is carried on by him or her shall be entitled to provide the insured services referred to in paragraph 3(b) of the Medical Care Insurance Insured Services Regulations. 69/03 s3 Back to Top Fee payment to physician or beneficiary 4. (1) The minister shall pay to a physician or to a beneficiary the fees listed in the fee schedule for the insured services provided to the beneficiary subject to the conditions and limitations contained in the Act. (2) An arrangement entered into under the Act may make provision for payments at negotiated rates and the minister shall instead of the payment required to be made by subsection (1) make a payment in accordance with that arrangement. (3) Where an insured service is rendered to a beneficiary by a physician who is a specialist and the beneficiary was not referred to that person by another physician or a person authorized by the minister to do so, the payment to the specialist for the service shall be an amount equal to the amount that is payable under these regulations to a physician in general practice for a service of the kind provided, except that (a) the specialist fee listed in the surgical procedures section of the fee schedule will be paid to a specialist who performs surgery within his or her field of practice; (b) the specialist fee listed in the diagnostic and therapeutic procedures section of the fee schedule will be paid to the specialist if it is the only applicable fee; and (c) the specialist fee for hospital visits in the consultations and visits section of the fee schedule will be paid to a specialist who carries out hospital visits within his or her field of practice on a beneficiary who has been admitted to hospital. (4) A payment shall not be made to a physician in respect of (a) the time taken or expenses incurred in travelling to consult a beneficiary; or (b) an insured service rendered to a beneficiary by a physician who is undergoing a period of clinical training unless that physician is providing coverage in a hospital casualty department or while he or she is on leave in accordance with a program approved for medical post graduate students by the Faculty of Medicine of Memorial University of Newfoundland. (5) Nothing in this section shall prevent the minister from entering into an agreement with a participating physician to provide insured services to beneficiaries for rates of payment negotiated between the minister and the participating physician and, upon an agreement being entered, the minister shall, instead of the payment required to be made by subsection (1), make a payment to the participating physician at the rate negotiated and approved. 69/03 s4 Back to Top Pattern of practice 5. For the purposes of paragraph 15(1)(c) of the Act the term "pattern of practice" means the number and type of insured services provided by a participating physician on a quarterly basis as computed by the minister. 69/03 s5 Back to Top Formula determining pattern of practice 6. (1) The formula for the determination of the average pattern of practice of participating physicians is the pattern of practice profile prepared quarterly by the minister. (2) For the purposes of subsection (1) the words "pattern of practice profile" mean the calculation by the minister of the number and type of insured services provided by participating physicians who are general practitioners in areas of the province as determined by the minister and for particular specialities and the average of insured services provided by those participating physicians calculated on a quarterly basis. 69/03 s6 Back to Top Insured services received out of province 7. (1) Where a beneficiary receives insured services outside the province but within Canada, the minister shall pay for those services the rates established by the public medical care insurance plan in the province or territory where the services were provided. (2) Where a beneficiary receives insured services outside Canada that are available in the province, the minister shall pay for those services the rates in the fee schedule. (3) Where a beneficiary receives insured services outside Canada that are not available in the province but are available within Canada, the minister shall pay for those services the rates established by the public medical care insurance plan in a province or territory selected by the minister in which the services are available. (4) Where a beneficiary receives insured services outside Canada that are not available within Canada after receiving approval from the minister to do so, the minister shall pay for those services at a rate that the minister considers fair and reasonable. (5) Where a beneficiary does not obtain the approval of the minister prior to receiving services outside Canada in accordance with subsection (4), the minister shall only be required to pay the rates established for similar services by the public medical care insurance plan in a province or territory selected by the minister. (6) A beneficiary claiming the cost of insured services under this section shall supply to the minister information that he or she requires relating to the services provided. 69/03 s7 Back to Top Application for payment of insured services 8. (1) All applications for payment of sums for the provision of insured services shall be made to the minister on forms set by the minister for that purpose and shall be signed by the physician or someone duly authorized on his or her behalf not later than 90 days after completion of the insured services in respect of which the application is made. (2) A person shall be considered to have been duly authorized to sign an application form on behalf of a physician after the minister has been notified in writing by the physician that such a person is authorized to do so and before the minister has been notified in writing by the physician that the authority has been revoked. (3) Notwithstanding subsection (1), the minister may extend the time for making application for payment under this section if good cause for the extension is shown. 69/03 s8 Back to Top Assignment of payments 9. (1) The minister may pay to the employer of a physician engaged under a contract of service or contract for services the amounts due to the physician under these regulations where that physician has assigned the right to receive the payment to the employer. (2) The minister shall have the right to approve the terms and conditions of an assignment of amounts due under these regulations before making payment to an employer under subsection (1). (3) Payment of amounts due under these regulations to a participating physician who is in partnership or works in association with other physicians may on the request of the participating physician be made to the partnership firm or the association of practitioners. 69/03 s9 Back to Top Disclosure 10. Every beneficiary who applies for payment or in respect of whom an application for payment is made under these regulations shall, if called upon by the minister disclose whether or not a person may have contributed to the illness for which insured services were provided. 69/03 s10 Back to Top Charges against beneficiary 11. The extent of the charges which may be made against the beneficiary under subsection 8(3) of the Act is the extent to which the fees payable by the minister for the non-referred insured services are exceeded by the fees payable by the minister for corresponding insured services which are referred. 69/03 s11 Back to Top Debt due to minister 12. (1) Amounts paid by the minister under these regulations to a participating physician or a beneficiary in respect of a service which is not an insured service or in respect of an insured service to a person who is not a beneficiary shall be a debt due by the person for whom the payment was made and may be recovered by the minister. (2) A sum paid by the minister in error, whether the payment was made to a participating physician or a beneficiary, shall be a debt due to the minister by the person to whom the payment was made and may be recovered by the minister. 69/03 s12 Back to Top Delegation by minister 13. The minister may delegate a power or authority granted to the minister under sections 4 to 12 and section 14 to a person employed under him or her, subject to those limitations, restrictions, conditions and requirements as the minister may impose. 69/03 s13 Back to Top Medical Consultant's Committee 14. (1) The Medical Consultants Committee shall, upon the request of the minister, review the patterns of practice and billing procedures of participating physicians and the utilization of services by beneficiaries and the committee shall advise the minister with respect to its findings. (2) Where the committee concludes that no corrective action is warranted beyond notification to the physician of a finding that a deviant pattern or unacceptable billing practice exists, that notification may be given or authorized by the committee. (3) Recovery of funds or other disciplinary or investigative action may be recommended by the committee to the minister. 69/03 s14 Back to Top Composition of committee 15. (1) The Medical Consultants Committee shall consist of: (a) a salaried general practitioner, a non-salaried general practitioner and a specialist appointed by the minister from a list of physicians submitted by the Newfoundland and Labrador Medical Association; (b) a chartered professional accountant appointed by the minister; and (c) the medical director, the assistant medical director and the dental director employed in the department. (2) The committee may invite the attendance and advice of legal counsel on a matter being considered. (3) The chairperson of the committee shall be the assistant medical director referred to in paragraph (1)(c). (4) The members of the committee appointed under paragraphs (1)(a) and (b) shall be appointed on terms and conditions that the minister may set, but a member appointed under paragraph (1)(a) may not serve longer than 5 consecutive years. (5) Members of the committee appointed under paragraphs (1)(a) and (b) who do not receive a salary from funds voted for the purpose by the legislature shall be remunerated on an hourly basis for their committee service. (6) Where the term of office of an appointed committee member expires, he or she shall continue to be a committee member until replaced. (7) A person appointed under paragraphs (1)(a) or (b) may resign as a committee member by written notice to the minister. (8) The committee shall meet at the call of the chairperson. (9) A quorum of the committee is 3 members, of which one shall be a physician appointed under paragraph (1)(a). (10) The committee may establish rules and procedures governing review and investigation of cases. (11) The committee's review and investigation of cases may include the following methods: (a) review of physician profiles which depict individual billing history as compared to area and provincial averages; (b) request and review of patient medical information, i.e., records, charts, reports, etc. which relate to services for which payment has been made; (c) review of reports, statistical data and other information prepared by medical audit staff; (d) review of evidence, including sworn statements, obtained from program beneficiaries; (e) interviews with physicians, patients or others who may be identified as being able to provide information relevant to any case; and (f) review of other information which may be of assistance to the committee in completion of its work. 69/03 s15 ; 2014 cC-10.1 s70 Back to Top Transitional 16. (1) The members of the committee appointed prior to the coming into force of this regulation shall cease to hold office on the coming into force of this regulation. (2) Where, before the day this regulation comes into force, an inquiry by the committee was commenced, the members of the committee appointed after this regulation comes into force may continue the inquiry and investigation under sections 14 and 15. 69/03 s16 Back to Top Repeal 17. The Medical Care Insurance Physicians and Fees Regulations , Consolidated Newfoundland and Labrador Regulation 1193/96, are repealed. 69/03 s17