22.2. Where the Board believes that services for which payment is claimed by a professional in the field of health or for which he has obtained payment in the preceding 60 months were services furnished in non-conformity with the agreement, the Board may refuse payment for such services or have them reimbursed by compensation or otherwise, as the case may be. Disputes resulting from this paragraph are settled by the council of arbitration instituted by section 54 in accordance with the terms and conditions and time limits provided for in the agreement.
Where, after an investigation, the Board believes that services for which payment is claimed by a professional in the field of health or for which he has obtained payment in the preceding 10 years were services that have not been furnished, that he has not furnished in person or that he has falsely described, or services that were non-insured services, services not considered insured by regulation or services not established as insured services by regulation, the Board may refuse payment for such services or have them reimbursed by compensation or otherwise, as the case may be.
In addition, the Board may impose on the health professional a monetary administrative penalty equal to 10% of the payment the health professional has claimed or obtained for services referred to in the first paragraph or 15% of the payment the health professional has claimed or obtained for services referred to in the second paragraph. It may collect the amount of the penalty by compensation or otherwise.
Before rendering its decision, the Board shall give the health professional at least 30 days’ notice, stating the acts alleged against him and, if applicable, the monetary administrative penalty that may be imposed, and allowing him an opportunity to present observations. At the expiry of the time limit, the Board shall notify its decision to the health professional in writing, with reasons.
In the cases provided for in this section, the burden of proof that the decision of the Board is ill-founded, is on the professional in the field of health.
A professional in the field of health who wishes to appeal a decision of the Board before the Superior Court or the Court of Québec according to their respective jurisdictions, must do so within 60 days of receiving such decision.
The amount of the payments that a health professional has obtained for services referred to in the first or second paragraph may be established by statistical inference on the sole basis of information obtained by a sampling of those services, according to a method consistent with generally accepted practices.
Notification of a notice of investigation to the health professional by the Board suspends the 60-month prescription provided for in the first paragraph or the 10-year prescription provided for in the second paragraph until the expiry of one year from the notification or until the investigation report is completed, whichever comes first.
For the purposes of this Act and within the scope of the basic prescription drug insurance plan, the second, fourth, fifth and sixth paragraphs, adapted as required, apply to an institution.
1979, c. 1, s. 16; 1981, c. 22, s. 8; 1996, c. 32, s. 96; 1999, c. 89, s. 28; 2016, c. 28, s. 1311.