Ontario’s auditor general finds the province is not properly monitoring doctors’ bills

The Auditor General has found that Ontario is not properly monitoring doctors’ bills, including cases of physicians billing more than 24 hours a day – money that could be better spent adding more family doctors.

Shelley Spence made the findings in her annual report released Tuesday, which includes a series of health audits that also found that too few family doctors are participating in the province’s Health Care Connect system — which is critical to helping Ontario meet its goal of connecting everyone to primary care — and that the government has not adequately planned for the expansion of its medical school.

As part of the health audit, Spence found that the Department of Health system that doctors have been using to bill OHIP for services provided to patients since the 1980s cannot automatically flag high-risk bills despite major technological advances since the Auditor General made similar findings about 10 years earlier.

“If there is waste in the billing system — and we’re not saying there is, we’re just saying it should be reviewed — and if it can be recovered, you can use that money to hire more family physicians,” Spence said.

An analysis of claims over the past three years found that at least 59 doctors each year billed for more than 24 hours of service a day, Spence wrote, with 82 doctors doing so in 2024-25.

They found that the ministry did not conduct a thorough review to determine causation or whether the time-based fee code needed to be updated, and did not use hourly billing data to select doctors for audits.

Spence wrote, “There may be legitimate reasons for billing a large number of hours in a day; however, without flagging these cases for review, the Ministry does not know whether the billings are appropriate.”

Some doctors billed for 366 days, treating 500 patients a day.

Also, more than 100 doctors submitted claims for working all 365 or 366 days a year in each of the past three years, which should have been flagged as high risk, the auditor said. Spence found that many physicians also billed for services provided to more than 500 patients in a single day and were not audited after payment.

The ministry has conducted some post-payment audits on high-billing doctors, including one case that identified overpayments of nearly $1.4 million to a doctor who billed more than 24 hours a day 98 times over two years, including billing for 114 hours of services in a day, the auditors wrote.

Health Minister Sylvia Jones was not available to answer questions on Tuesday and Jones’ parliamentary assistant, Anthony Lerdy, defended the current system.

“The first thing we need to appreciate about the billing system is that it involves a very complex system, which is the health care system … there are actually about 5,000 different billing codes under the provincial health care system and that’s a lot of billing codes, and sometimes those processes overlap with each other,” Lerdy said at a news conference.

“So we don’t have to automatically jump to any assumptions.”

Shortly after the news conference, Jones’ office issued a statement saying the ministry was looking into the matters raised by the auditor and would take action if wrongdoing was confirmed.

NDP Leader Marit Stiles called the billing findings “bananas”.

“It’s not really about individual doctors, it’s about the fact that the government refuses to hire enough people to oversee these things,” he said.

Spence said cases for the ministry’s audits are identified largely through tips and complaints, which is a reactive approach rather than a proactive one. He said the ministry’s audits recovered $8.1 million between 2022 and 2025, but adding more staff to the audit division could increase that number. Spence noted that the ministry asked the government for more audit staff in 2017 but the number remained at eight.

The Ontario Medical Association and the Ministry of Health agreed to reduce “medically unnecessary services” such as “low-value” tests to save $480 million a year in 2019, but have received only $87 million of that so far, the auditor wrote.

Problems related to Health Care Connect system

The health minister has said the province is committed to connecting all Ontarians to primary care by 2029, but the auditor said the province’s Health Care Connect system is not as effective as it could be, leading to longer wait times.

While half of the 197,000 people referred to family doctors through the waiting list since 2020 waited less than 21 days, as of June more than 100,000 were still waiting for more than a year.

The government claims to have halved the waiting list, but auditors said Tuesday the number of people on that list does not represent the true need for primary care, because only 11 percent of people without a family doctor are registered and only seven percent of doctors who work under the patient enrollment model accept patients who register through Health Care Connect.

Lerdy downplayed the importance of those Auditor General findings, saying that many people are finding doctors and nurse practitioners without it.

“Health Care Connect is just one tool to connect yourself to primary care,” he said.

The government’s “Find a Doctor or Nurse Practitioner” website says there are two ways to connect with a family doctor. One is to register with Health Care Connect and the other is to call the doctors personally.

The ministry and Ontario Health said in an internal review two years ago that lack of awareness of Health Care Connect was an issue, but did nothing to improve it, the auditors wrote.

Also, the auditor found that the government’s plan to add 340 undergraduate and 551 postgraduate medical school seats with a focus on family medicine was based on an underestimate of how many people have no primary care provider.

The decision was made in part using an estimate of 1.3 million Ontarians who need a family doctor but don’t have one, the auditor said, an estimate that came from a 2022 voluntary telephone survey of Ontarians’ experiences with the health-care system.

The ministry recently conducted an analysis from its own database in consultation with a group of researchers and estimated that two million Ontarians are “uninsured,” which the auditor said would require about 2,000 more family doctors to care for all of them.