Billing dispute infuriates Montreal ER doctors, sparks mass-resignation threat.

© 1999 Susan Pinker B y the time summer arrived in Montreal on June 21, the temperatures of all 19 emergency physicians at the Royal Victoria Hospital had already reached the boiling point. They submitted their resignations en masse, asserting that that they are being harassed by the Régie de l’assurance-maladie du Québec (RAMQ), which for the third time in 10 years is investigating their billing practices. The resignations take effect Sept. 1. “Right now we cannot envision practising emergency medicine in Quebec under these conditions,” says Dr. Marc Béïque, spokesperson for the doctors. “We’ve explored every way to come to a compromise, to solve this problem, and the answer from Quebec has been a flat no. Within a few weeks, we’ll start looking for jobs elsewhere.” The conflict centres on the frequency of major complete exams in the emergency room. The régie, the agency billed by doctors, claims that ER physicians at the Royal Vic are conducting major complete exams, which require a thorough medical and family history and the investigation of all systems, at 4 to 6 times the rate found in other Quebec emergency rooms. A major complete exam costs the province $38, whereas a complete exam is billed at only $21. “It’s the pertinence of these exams that we’re questioning,” says Pierre Boucher, an RAMQ spokesperson. “We do examine the billing profile of every physician in Quebec and compare it to [that of] other physicians doing the same work. We single out any physician who bills more than his colleagues and submit the profile to a peer-review committee.” And there’s the rub. The Royal Vic’s ER physicians consider emergency medicine a recognized medical specialty. They are angry that the peer-review committee contains only family physicians, and not trained emergency specialists. “Every other province and all 50 states consider it its own specialty,” complains Béïque. “Quebec is the only province that considers them family practice physicians. We’re giving the North American standard of care.” The Vic’s emergency physicians were also targeted for investigation in 1990/91 and in 1996. “They came, they looked at the charts, and the investigators said they were satisfied with the way we were practising,” says Béïque. “If everything is fine, why are they investigating us again?” During the past year the 19 doctors have been interviewed at length by investigators and have had their charts pulled. Béïque alone had to spend 4 days preparing for his interview, and then another 5 hours responding to the investigator’s queries. Fifteen of the 19 emergency physicians at the Royal Victoria have undergone these investigations. The 4 doctors who have not been investigated resigned to show solidarity with their colleagues. One of the most contentious issues is reimbursement. According to staff at the régie, the Quebec Health Act allows them, via the peerreview committee, to assess 3 years of medical charts in order to determine whether certain procedures were justified. Given their rate of major complete exams, the emergency doctors at the Vic expect that they will be asked to return hundreds of thousands of dollars — the difference between their billings and the statistical average, retroactive to 1996. This is a frightening prospect to many of them. “We’re not doing anything forbidden,” says Dr. Lorne Wiesenfeld, one of the physicians being investigated. “We think the exams are medically indicated. If I have to pay back $90 000, I’ll leave Quebec and I’ll never come back.” At the heart of the matter is whether quality-of-care decisions can be separated from fiscal ones. The régie says that the 2 issues can be examined independently, especially as the Quebec Health Act prohibits it from determining when clinical acts are warranted. “We’re not questioning the quality of service at the Vic,” says Boucher. “We’re just questioning the billing practices.” But the Royal Vic’s physicians beg to differ. “We do more thorough exams but fewer repeat exams,” argues Béïque. “And the cost per patient per episode of care is average compared to other large teaching institutions. I guarantee that overall what the emergency physicians here get paid is average. The régie alleges that the comprehensive exams were not always medically necessary and were therefore provided more frequently than required. In our view, patients are not statistics.”