Health P.E.I. has been overpaying Ontario firm for radiology services for years, watchdog says

Health P.E.I. has been overpaying by as much as 100 per cent for off-hours radiology services provided through an Ontario company, according to the province's auditor general.

In a report released Tuesday, the office of Auditor General Darren Noonan said the issue has been raised with the province's health authority annually since the audit of its 2021 financial statement, yet it still has not been addressed.

What's more, the AG's report says the single position designated within Health P.E.I. to audit medical claims has been mostly vacant since April 2022, with no one else given responsibility for analyzing claims or recovering overpayments for erroneous billings.

No audits of physician billing have been performed in that time.

'Taxpayers paid more than they should have'

Radiologists are doctors who interpret images from X-rays, MRIs and other diagnostic images.

Health P.E.I. has an agreement with a private company to provide after-hours radiology services using off-Island radiologists. The name of the company is not included in the AG's report.

The payments include premiums of 25 to 100 per cent, depending on time of day, to provide emergency service. But those services have to be delivered within 30 minutes in the case of a possible stroke, or within 60 minutes for other emergencies.

The AG's office analyzed a sample of 30 after-hours radiology billings and found that in almost half of them, premiums were paid for emergency services when they should not have been.

"In these cases, taxpayers paid more than they should have for these services," the report says.

In one case examined by the AG's office, a premium was paid for one-hour emergency service when the report on the image came back 36 hours after it was sent.

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According to the AG's report, staff within Health P.E.I.'s Medicare office noticed some radiology reports were incurring emergency premiums even though the reports didn't come back within the required timelines.

They asked whether they should pay the claims, or if they should start monitoring them more closely.

They were advised to pay them, and to "disregard whether the teleradiologist read the image in the required timelines."

Health P.E.I. has a policy in place that requires Medicare staff to monitor and recover any identified overbillings.

The AG's office found that many employees, including Health P.E.I.'s senior fiscal analyst, were not aware of the existence of the policy.

In its response to the report, Health P.E.I. said it agreed the premiums for emergency radiology services should only be paid when the required timelines are met.

The agency said relevant policies would be re-circulated to staff responsible for after-hours premium payments, and orientation and onboarding for staff responsible for physician billings analysis and audit would be modified to ensure they have all the information necessary for their roles.

It said this is an area where it has "experienced significant staffing vacancies and turnover."

Looking for company to audit billings

Health P.E.I. also said it recognizes "the need to make improvements to claims monitoring, compliance and recovery processes to identify and correct overbillings."

The agency said it plans to introduce a new annual physician audit plan this fall, but that depends on finding an external company to provide that service.

Neither Health P.E.I. nor the auditor general put a dollar amount on how much might have been overpaid on after-hours radiology premiums. And there was no response in time for publication from Health P.E.I. on whether it intends to try to recoup that money.

Noonan's report shows that fees paid to radiologists were in the range of $11 million in 2024, representing a $4 million increase over the last five years.

Health P.E.I. paid more than $450,000 in after-hours premiums to radiologists in fiscal 2024.

"One of the biggest responsibilities for government is the stewardship of taxpayer dollars," Noonan told CBC News.

"Ensuring that taxpayer money is spent wisely and appropriately is a key responsibility for [Health P.E.I.]. That's the main reason why this is important."