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Control measures

As of December 7, 2016, RAMQ has new legal tools with which to carry out its mission and optimally perform its monitoring activities.

These tools will enable it to efficiently intervene when alleged irregularities and fraud are observed involving:

  • non-authorized benefits received or granted by drug manufacturers, wholesalers, intermediaries, including chains and groups, and pharmacists
  • false or untruthful statements
  • claims and requests for payment sent to RAMQ
  • fees billed to insured persons
  • a Health Insurance Card obtained or used illegally
  • compliance on the part of drug manufacturers and wholesalers with their respective commitments

Powers adapted to various clienteles

Here are the powers entrusted to RAMQ and the changes now in effect for each clientele. In each case, the section corresponding to the Compilation of Québec Laws and Regulations is provided in parentheses. These sections come under the Health Insurance Act (HIA) the Act respecting prescription drug insurance (ARPDI) and the Act respecting the Régie de l’assurance maladie du Québec (ARRAMQ).

  • Whoever has assisted or encouraged a person in obtaining a Health Insurance Card without being entitled to it will be required to repay RAMQ any amounts due, solidarily with the person who received covered services without being entitled to them. (HIA, s. 9.7)
  • Whoever encourages, advises, authorizes or obliges another person to provide information that he or she knows to be false or inaccurate is liable to a fine of $1,000 to $10,000. (ARPDI, s. 82)
  • An insured person may access, on the date the service was furnished, the name and address of the person who furnished the service, the description of this service and the sums paid by RAMQ. (HIA, s. 64)
  • No group insurance contract or employee benefit plan may restrict a beneficiary’s freedom to choose a pharmacist. (ARPDI, s. 42.2.1)

Fines, penalties and recovery of amounts

  • Fines, previously ranging from $1,000 to $2,000 and $2,000 to $5,000 for subsequent offences, have increased substantially and may reach $150,000. (HIA, s. 22)
  • Monetary administrative penalties have been added: 10% of a payment that a health professional has claimed or obtained for services in contravention of the agreement or 15% for a payment that a health professional has claimed or obtained for services not furnished, not furnished in person, falsely described or not covered. (HIA, s. 22.2 and s. 50)
  • For providers of insured services, provisions similar to those applicable to health professionals apply, for instance, concerning the recovery by RAMQ of non-authorized payments being claimed or having been obtained by these providers. (HIA, s. 38.1 and following)
  • RAMQ has the authority to recover, by compensation (withholding part of any amount) or otherwise, any amount paid to a health professional or third party in contravention of the Health Insurance Act, without the insured person having submitted a request for reimbursement to RAMQ. (HIA, s. 22.0.1)
  • Whoever assists or encourages a person in obtaining or receiving from RAMQ, directly or indirectly, the benefit of services that this person is not entitled to obtain or receive is liable to a fine of $1,000 to $10,000. It is also forbidden to knowingly assist or encourage a person to obtain the benefit of services in an excessive or unjustified manner. For a repeat offence, the minimal and maximum fines have been doubled. (HIA, s. 74)
  • Where a health professional has obtained a payment for services furnished in contravention of the agreement, not furnished or falsely described, the penalty may be established by statistical inference on the sole basis of information obtained by sampling of those services. (HIA, s. 22.2)

Inspection, investigation and disclosure of information

  • The powers of inspection conferred to RAMQ enable it to require from a person any information or document related to the activities and duties of health professionals or providers of insured services. Anyone hindering the work of an inspector or investigator is guilty of an offence and liable to a fine. (ARRAMQ, s. 20.1 et 21)
  • RAMQ can request any document or information contained in the record of an insured person while ensuring its confidentiality. (ARRAMQ, s. 20.1)
  • RAMQ may ask that a judge of the Superior Court issue an injunction to terminate practices that contravene a provision of the laws that it is responsible for applying. (ARRAMQ, s. 21.1)
  • In certain circumstances, a RAMQ decision rendered with respect to a health professional, third party or provider is public information. (HIA, s. 22.6)
  • RAMQ may disclose information obtained for the carrying out of the Health Insurance Act to bodies responsible for the prevention, detection and repression of crime. (HIA, s. 65)
  • The period of prescription is increased from 36 to 60 months for services furnished in contravention of the agreement and 10 years for services not furnished, not furnished by the professional in person, falsely described or not covered. (HIA, s. 22.2)
  • The prescription applicable to a claim by RAMQ against a health professional, health provider or intermediary is suspended effective from the issuance of a notice of investigation, for a period of 1 year or until the closeout investigation report has been tabled, whichever occurs first. (HIA, s. 22.2)
  • The time limit for a health professional or third party to contest a RAMQ decision targeting non-authorized payments has been reduced: from 6 months to 60 days following notice of the decision. (HIA, s. 22.0.1)

Coverage, payment and reimbursement of prescription drugs

  • The Minister of Health may suspend the insurance coverage of a prescription drug or supply of a manufacturer, end it or not re-enter this drug or supply when the List of Medications is updated, in the following cases where:
    • a manufacturer fails to comply with one of the conditions or commitments prescribed by ministerial regulation, a provision of a listing agreement or a provision of a contract entered into following a call for tenders
    • the selling price guaranteed by the manufacturer for a prescription drug is higher than the maximum amount payable by the basic plan
    • a competing drug or supply is the subject of a listing agreement
    • the Institut national d’excellence en santé et en services sociaux recommends doing so
    • the Minister considers that the public interest so requires it (ARPDI, s. 60.0.4)
  • The Minister may determine the conditions for which the payment of the cost of prescription drugs, including exceptional medications, is covered by the basic plan, in particular:
    • the therapeutic indications concerned
    • the maximum quantity covered for a given drug
    • the duration of the pharmacological treatment
    • the necessity of obtaining RAMQ authorization
    • the restrictions relating to the age of an eligible person (ARPDI, s. 60)
  • Pharmacists and preparing pharmacists are not allowed to sell to insured persons covered by the basic plan drugs covered under that plan at a price other than that which they themselves paid. For drugs having to be prepared, that price will include the price covered under the basic plan for all the ingredients used for the preparation, along with the fee of the preparing pharmacist, set according to the rates in the agreement referred to in section 19 of the Health Insurance Act. The Act provides that this provision will come into effect by government order in council. (ARPDI, s. 8.1.2)

Fines, penalties and recovery of amounts

  • Fines have been increased substantially: they may reach $1 million for manufacturers, wholesalers and intermediaries. (ARPDI, s. 81 and following) For subsequent offences, the fines may double. (ARPDI, s. 85.0.2)
  • Monetary administrative penalties have been added: 15% of the amount for which manufacturers, wholesalers or intermediaries are liable following an investigation. (ARPDI, s. 80.4)
  • Where, after an investigation, RAMQ believes that a pharmacist has received rebates, gratuities or other benefits not authorized by government regulation for pharmaceutical services or prescription drugs, it may deduct an amount corresponding to the value of the rebates, gratuities or other benefits from the payment for those pharmaceutical services or prescription drugs or obtain the reimbursement of that amount by way of compensation or otherwise. (ARPDI, s. 22)

Forbidden commercial practices

  • Certain commercial practices between manufacturers, wholesalers and intermediaries are forbidden, for instance, exclusivity with respect to supplying a pharmacy with prescription drugs or supplies appearing on the List of Medications. (ARPDI, s. 80.1)
  • Accredited manufacturers and wholesalers, as well as intermediaries and owner pharmacists may not grant, directly or indirectly, any benefits related to the sale or purchase of drugs appearing on the List of Medications to prescribers, operators or employees of the private nursing homes specified in the Act respecting health services and social services. It is also forbidden for these persons to grant or receive such benefits. (ARPDI, s. 80.3)
  • It is forbidden for accredited manufacturers or wholesalers as well as intermediaries to pay or to reimburse, in full or in part, persons covered by the basic plan for the price of prescription drugs or supplies covered by that plan, except to the extent provided by regulation of the Minister, for instance, for humanitarian reasons. (ARPDI, s. 80.2)

Pharmacists’ invoice

Effective from September 15, 2017, pharmacists must include the following on their invoices:

  • the price charged for each covered drug
  • the wholesaler’s mark-up
  • the various professional fees claimed
  • the insured person’s contribution (ARPDI, s. 8.1.1)

Procurement of supplies and prescription drugs

  • Accredited manufacturers and wholesalers, and intermediaries are required to supply all pharmacists who so request it when there is a serious risk that prescription drugs may run out of stock and when the Minister has issued a notice in that regard. (ARPDI, s. 60.0.5)

To find out more, read the Bill 92.

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