A-29 - Health Insurance Act

Section 22.0.1 Disposition versions

2017-03-07

22.0.1. Where the Board believes that a health professional or third person has received payment from an insured person contrary to this Act, including if the health professional or third person has exacted more than the amount that would have been paid by the Board to a professional subject to the application of an agreement for the services provided to an insured person who did not present his health insurance card, claim booklet or eligibility card, it shall notify the health professional or third person in writing. The notice must also indicate the reimbursement mechanisms that the Board may apply under this section and, if applicable, the monetary administrative penalty that may be imposed, and allow the health professional or third person 30 days to present observations.

At the expiry of the 30-day period, the Board shall notify its decision to the health professional or third person in writing, with reasons. If the Board maintains that an amount has been so paid, it shall reimburse the amount to the insured person in respect of whom it has, within five years after payment is made, written proof of the payment.

The Board may

(1)  inform the insured persons concerned by any means it considers appropriate, such as by publishing a notice to that effect on its website or in a newspaper in the locality where the health professional practises, that they may file an application for reimbursement with the Board within five years of the date of payment;

(2)  recover from the health professional or third person, by compensation or otherwise, any amount received contrary to this Act, whether or not the Board has received an application for reimbursement, such an amount then being deemed to be a debt toward the Board; and

(3)  impose on the health professional or third person a monetary administrative penalty equal to 15% of the payment received contrary to this Act, which it may collect by compensation or otherwise.

If the five-year period referred to in the second paragraph has expired, the Board may not take any recovery measure under subparagraph 2 of the third paragraph in respect of an amount for which it has not received an application for reimbursement.

If the third person having received the prohibited payment is the operator of a private health facility or specialized medical centre where the health professional named in the application for reimbursement or affected by the recovery measure practises, or if the third person manages the business of the health professional, compensation may be applied against that health professional, except as regards the monetary administrative penalty, provided the health professional has been notified in accordance with the first paragraph.

The health professional or third person may, within 60 days of notification of the decision, contest the decision before the Superior Court or the Court of Québec, according to their respective jurisdictions. The burden of proving that the decision of the Board is ill-founded is on the health professional or third person, as the case may be.

If the health professional or third person does not contest such a decision and the Board cannot recover the amount owing by compensation, the Board may, at the expiry of the 60-day period for contesting the decision, issue a certificate stating the name and address of the health professional or third person and attesting the amount owing and the health professional’s or third person’s failure to contest the decision. On the filing of the certificate with the office of the Superior Court or the Court of Québec, according to their respective jurisdictions, the decision becomes enforceable as if it were a final judgment of that court not subject to appeal and has all the effects of such a judgment.

The second paragraph of section 18.3.2 applies, with the necessary modifications, to the amount owed by the health professional or third person.

1989, c. 50, s. 28; 1999, c. 89, s. 26, s. 42; 2015, c. 25, s. 1; 2016, c. 28, s. 12.

2016-12-07

22.0.1. Where the Board believes that a health professional or third person has received payment from an insured person contrary to this Act, including if the health professional or third person has exacted more than the amount that would have been paid by the Board to a professional subject to the application of an agreement for the services provided to an insured person who did not present his health insurance card, claim booklet or eligibility card, it shall notify the health professional or third person in writing. The notice must also indicate the reimbursement mechanisms that the Board may apply under this section and, if applicable, the monetary administrative penalty that may be imposed, and allow the health professional or third person 30 days to present observations.

At the expiry of the 30-day period, the Board shall notify its decision to the health professional or third person in writing, with reasons. If the Board maintains that an amount has been so paid, it shall reimburse the amount to the insured person in respect of whom it has, within five years after payment is made, written proof of the payment.

The Board may

(1)  inform the insured persons concerned by any means it considers appropriate, such as by publishing a notice to that effect on its website or in a newspaper in the locality where the health professional practises, that they may file an application for reimbursement with the Board within five years of the date of payment;

(2)  recover from the health professional or third person, by compensation or otherwise, any amount received contrary to this Act, whether or not the Board has received an application for reimbursement, such an amount then being deemed to be a debt toward the Board; and

In force: 2017-03-07

(3)  impose on the health professional or third person a monetary administrative penalty equal to 15% of the payment received contrary to this Act, which it may collect by compensation or otherwise.

If the five-year period referred to in the second paragraph has expired, the Board may not take any recovery measure under subparagraph 2 of the third paragraph in respect of an amount for which it has not received an application for reimbursement.

If the third person having received the prohibited payment is the operator of a private health facility or specialized medical centre where the health professional named in the application for reimbursement or affected by the recovery measure practises, or if the third person manages the business of the health professional, compensation may be applied against that health professional, except as regards the monetary administrative penalty, provided the health professional has been notified in accordance with the first paragraph.

The health professional or third person may, within 60 days of notification of the decision, contest the decision before the Superior Court or the Court of Québec, according to their respective jurisdictions. The burden of proving that the decision of the Board is ill-founded is on the health professional or third person, as the case may be.

If the health professional or third person does not contest such a decision and the Board cannot recover the amount owing by compensation, the Board may, at the expiry of the 60-day period for contesting the decision, issue a certificate stating the name and address of the health professional or third person and attesting the amount owing and the health professional’s or third person’s failure to contest the decision. On the filing of the certificate with the office of the Superior Court or the Court of Québec, according to their respective jurisdictions, the decision becomes enforceable as if it were a final judgment of that court not subject to appeal and has all the effects of such a judgment.

The second paragraph of section 18.3.2 applies, with the necessary modifications, to the amount owed by the health professional or third person.

1989, c. 50, s. 28; 1999, c. 89, s. 26, s. 42; 2015, c. 25, s. 1; 2016, c. 28, s. 12.

2015-11-10

22.0.1. Whenever the Board believes that a professional in the field of health or a third person has exacted payment from an insured person in contravention of this Act, where nothing in the regulations so permits, or has claimed an amount exceeding the amount that would have been paid by the Board to a health professional subject to the application of an agreement for insured services furnished to an insured person who failed to present his health insurance card, claim booklet or eligibility card, it shall reimburse the amount so paid by the beneficiary and notify the professional or the third person in writing thereof. The Board shall make such a reimbursement solely where the insured person applies therefor in writing within one year after the date of payment.

An amount so reimbursed and the administrative costs prescribed constitute a debt toward the Board and may be recovered from the professional in the field of health or third person by compensation or otherwise, on the expiry of a period of 30 days from the date of the notice.

Within six months of the compensation, the professional in the field of health may appeal from the Board’s decision before the Superior Court or the Court of Québec according to their respective jurisdictions or, in the case of a question of interpretation or application of an agreement, before a council of arbitration established under section 54. The burden of proving that the decision of the Board is ill-founded is on the health professional.

1989, c. 50, s. 28; 1999, c. 89, s. 26, s. 42; 2015, c. 25, s. 1.

2000-03-01

22.0.1. Whenever the Board believes that a professional in the field of health or a third person has exacted payment from an insured person in contravention of this Act, where nothing in the regulations or agreements so permits, or has claimed an amount exceeding the amount that would have been paid by the Board to a health professional subject to the application of an agreement for insured services furnished to an insured person who failed to present his health insurance card, claim booklet or eligibility card, it shall reimburse the amount so paid by the beneficiary and notify the professional or the third person in writing thereof. The Board shall make such a reimbursement solely where the insured person applies therefor in writing within one year after the date of payment.

An amount so reimbursed and the administrative costs prescribed constitute a debt toward the Board and may be recovered from the professional in the field of health or third person by compensation or otherwise, on the expiry of a period of 30 days from the date of the notice.

Within six months of the compensation, the professional in the field of health may appeal from the Board’s decision before the Superior Court or the Court of Québec according to their respective jurisdictions or, in the case of a question of interpretation or application of an agreement, before a council of arbitration established under section 54. The burden of proving that the decision of the Board is ill-founded is on the health professional.

1989, c. 50, s. 28; 1999, c. 89, s. 26, s. 42.

1989-06-22

22.0.1. Whenever the Board believes that a professional in the field of health or a third person has exacted payment from a beneficiary in contravention of this Act, where nothing in the regulations or agreements so permits, it shall reimburse the amount so paid by the beneficiary and notify the professional or the third person in writing thereof. The Board shall make such a reimbursement solely where the beneficiary applies therefor in writing within six months after the date of payment.

An amount so reimbursed and the administrative costs prescribed constitute a debt toward the Board and may be recovered from the professional in the field of health or third person by compensation or otherwise, on the expiry of a period of 30 days from the date of the notice.

Within six months of the compensation, the professional in the field of health may appeal from the Board’s decision before a court of civil jurisdiction or, in the case of a question of interpretation or application of an agreement, before a council of arbitration established under section 54.

1989, c. 50, s. 28.