Face of Nation : On a January day in 2017, a woman visited family physician Rajiv Kumra at a medical clinic in Etobicoke’s Six Points Plaza.
We don’t know what the woman’s health concern was, but according to a recent disciplinary hearing, we know Kumra billed the Ontario Health Insurance Plan (OHIP) for her visit — as well as for her five children, who were not even there.
The previous summer, in August 2016, Kumra billed OHIP for a father and his six children at the same clinic, when just the father saw the doctor that day.
Between November 2012 and November 2014, Kumra billed OHIP a dozen times for another man who typically visits the doctor just once a year. On 11 of those occasions, Kumra also billed for at least 10 of the man’s other household family members.
These are just a few of more than 20 instances between 2012 and 2017 when Kumra billed for members of entire families after just one attended his medical clinic for care, according to the College of Physicians and Surgeons of Ontario (CPSO), which regulates the province’s medical profession.
Kumra did not contest the CPSO’s discipline committee findings at a hearing June 17. A “no contest” plea means a doctor isn’t admitting guilt, but does not contest the facts and accepts that the discipline committee can find the facts correct, according to the CPSO.
Kumra surrendered his licence this spring, ending his 30-year medical career in Canada.
The doctor did not agree to an interview for this story or answer specific questions about the CPSO findings.
In an emailed statement to the Star, Kumra said he denies the allegations of professional misconduct and incompetence contained in an earlier notice to appear before the CPSO’s discipline committee.
“As my counsel stated at the hearing, I … dispute all of the factual assertions that ground the discipline findings,” he wrote.
“However, as a matter of practicality, and convenience, I chose to resolve all regulatory matters in Canada on the basis of a no contest plea,” he added in the statement forwarded by his lawyer Seth Weinstein.
Kumra is not among the province’s Top 100 OHIP billers, a list the Star obtained after a five-year quest to lift the veil of secrecy on physicians who receive the most from the public purse. While some have histories of overbilling or professional misconduct, most have no record of cautions or discipline with the CPSO.
Kumra’s case is an example of how a small number of physicians abuse the system and why proper oversight and transparency of all doctor billings — both large and small — is needed to protect the public from fraud and ensure scarce health dollars are spent properly.
A summary of his case, recently posted on the CPSO’s website, also offers a rare look at how college investigators, along with private surveillance and forensics experts, gather evidence to catch physicians suspected of improper billing.
“This is truly one of the most egregious cases of overbilling I have ever seen. And I’ve seen a lot of these,” said medical malpractice lawyer Paul Harte, who has been representing patients of incompetent and unscrupulous doctors for more than 20 years. He was not involved in Kumra’s case.
In publishing data about the Top 100 OHIP billers, the Star is revealing how tax dollars are spent and pressing for greater transparency in a cash-strapped health system. Ultimately, the hope is that there will be proactive billing disclosure for all 31,500 Ontario doctors. Physician compensation costs Ontario about $12 billion annually, and makes up about 8 per cent of the entire provincial budget.
The value of Kumra’s billings remain secret. That is because privacy legislation prevents the health ministry from disclosing information about individual doctors. The legislation also prevents the ministry from saying what, if any, action it is taking to recoup money from Kumra’s questionable billings in the wake of the CPSO findings.
Kumra, a 55-year-old graduate of the University of Toronto medical school, submitted improper OHIP bills while working at four medical offices, including clinics in the Six Points Plaza, on Trethewey Dr., and Lawrence Ave. W. in Toronto, and on Glenanna Rd. in Pickering, according to the CPSO.
The regulator would not say how they first identified Kumra as a problem biller. But in cases involving questionable doctor billing, the CPSO works closely with OHIP and the health ministry, which controls and regularly monitors the data, said CPSO spokesman Shae Greenfield.
In Kumra’s case, the CPSO hired private investigators to conduct surveillance on the doctor’s medical practices at the Six Points Plaza and on Trethewey Dr., according to the disciplinary hearing summary. When investigators compared their surveillance with OHIP billing data, it showed Kumra billed for people who did not attend either clinic.
For example, on Sept. 3, 2016, Kumra billed OHIP for more than four-times as many children observed entering the clinics. Investigators saw a total of 10 children and teens entering both clinics on that date, and yet Kumra billed for 46 young patients.
A similar pattern emerged when investigators conducted surveillance at the two locations again on Aug. 20, 2017. A total of 19 children and teens were observed going into the clinics that day. But Kumra billed OHIP for services provided to 53 people under age 19.
In addition to irregular OHIP billing, Kumra also regularly took cash from some of his lowest-income patients for a service that is also covered by provincial medical insurance, the CPSO says.
People on social assistance who have approved medical conditions that require a special diet, such as diabetes or lactose intolerance, can get extra money from the government to help with food costs.
But first they need a doctor or other health care professional to diagnose the condition and fill out a Special Diet Allowance form, a service for which physicians can bill OHIP.
In Kumra’s case, the discipline committee found that between 2010 and 2016, the doctor improperly charged patients $50 to complete each form in addition to billing OHIP for the same service. In 2016, he raised the price to $100 per form.
Twice between 2013 and 2016, a mother on welfare paid Kumra $350 for herself and her three children to have the doctor complete special diet forms, according to the hearing summary.
In the fall of 2014, when social assistance officials began rejecting forms signed by Kumra, the doctor arranged for a physician friend to come to his clinic once a week to sign the forms instead. Kumra and his friend shared the cash paid by patients, the summary says.
The arrangement stopped in May 2015 when the province resumed accepting special diet forms signed by Kumra, it adds.
On numerous occasions, the CPSO struggled to obtain Kumra’s patient records, according to the summary, including an attempt on July 7, 2017, when the doctor appears to have actively interfered with investigators’ efforts.
CPSO investigators and an independent forensic expert arrived at Kumra’s clinic in a two-storey medical building on Glenanna Rd. in Pickering where Kumra’s wife owns a medical imaging clinic, the summary says.
Kumra didn’t show up for the CPSO’s visit, claiming he was too ill even to speak on the phone. His patients were also left languishing in the waiting room, according to the hearing summary. Undeterred by Kumra’s absence, investigators contacted his lawyer to gain access to the doctor’s computer.
But as investigators were searching Kumra’s computer, suddenly the connection to the medical records server was lost. When investigators tried to locate the server in a utility closet in his wife’s imaging clinic down the hall, investigators spotted her receptionist “with a cellphone to her ear, carrying a large bag,” the summary says.
The receptionist initially denied it, but later admitted she was speaking with Kumra on her cellphone, according to the CPSO.
Although the receptionist refused to show investigators the contents of her bag — and they had no authority to force her to do so — the discipline committee concluded she was carrying the server.
“Dr. Kumra directed the receptionist to disconnect the (electronic medical records) server while the college was in attendance and to remove it from the premises,” the hearing summary says.
Investigators were eventually able to obtain 27 patient records from Kumra and the CPSO hired Dr. Jeff Bloom, family physician-in-chief at the University Health Network, to examine them.
In a report Bloom prepared for the discipline hearing, he concluded Kumra “failed to maintain the standard of practice of the profession and displayed a lack of judgment, including with respect to the completion of Special Diet Assistance forms, his billing practices and his administrative/managerial oversight of his electronic medical records and office practices.”
Specifically, Bloom noted there was no documentation to support conditions identified on many patients’ special diet forms and that he identified food allergies and intolerances despite contradictory medical evidence in the files.
In many cases, there was no documented history or physical exam to support “the significant number” of medical imaging studies Kumra ordered.
In some instances, there were multiple versions of documentation for the same visit and/or documentation identical to that found in other charts, Bloom said.
There were OHIP billings for which there were no patient records, and/or insufficient documentation to support OHIP billings, he said.
Kumra, who has a history of opioid abuse, according to a previous CPSO discipline case, had his licence suspended for eight months in 2007 for working while receiving disability insurance during an addiction relapse. Kumra’s appeal of the suspension was dismissed. In addition to his licence suspension in that case, Kumra was reprimanded by the CPSO and by the Medical Board of California, where he is also licensed, for making “false representations regarding his capacity to function as a physician in order to collect disability insurance.”
Kumra is also licensed to practise medicine in New York, according to the state medical board. The board lists no record of disciplinary findings on Kumra’s licence, although the doctor discloses the public reprimand from California under “out-of-state actions” on his online physician profile. In the disclosure, Kumra denies he did anything wrong.
In the face of the Ontario regulator’s latest findings, Kumra agreed never to apply or reapply for registration as a physician in Ontario or any other jurisdiction in Canada, according to a legal Undertaking, Acknowledgment and Consent document he signed April 26, posted on the CPSO website.
The CPSO agreed to suspend all new investigations into Kumra’s standard of practice and conduct in exchange for his decision to quit, according to the document.
At his June 17 hearing, the discipline committee ordered Kumra to receive a formal reprimand and pay $6,000 in costs to the CPSO. The regulator has no power to order physicians to repay the public in cases of overbilling.
A date for Kumra’s reprimand has not yet been set.
Kumra’s undertaking to surrender his licence was sent to American and other international medical authorities, as is the case with all Ontario disciplinary action, spokesman Greenfield said. It is up to those authorities to act in their jurisdictions, he added. Kumra is still licensed to practise medicine in California and New York.
Between 2013 and 2018, the college investigated 262 cases of improper billing, Greenfield said. Of those, a total of 48 investigations involving 37 physicians were sent for 38 public discipline hearings (one physician has two cases). The hearings resulted in 29 physicians receiving findings of professional misconduct. Three resigned and promised not to reapply for a licence. Seven doctors are still awaiting a hearing or an outcome.
The cases not sent to discipline hearings resulted in a range of outcomes, including no further action taken, cautions and orders to take training courses.
Between 2011 and 2018, the Ministry of Health and Long-Term Care referred 19 cases to the OPP, a ministry spokesman said.
Four OHIP billing cases resulted in Criminal Code charges: Three ended up in convictions and the fourth doctor was convicted under the Health Insurance Act, the ministry said.
Although the CPSO does not discuss details beyond what is published in a particular case, Greenfield said OHIP irregularities like those in the Kumra case are typically identified by OHIP and the health ministry, which owns the data and regularly monitors billings for fraud.
When the CPSO becomes aware of an OHIP billing problem with a physician, it works with OHIP and the health ministry, he said.
“We also have strong relationships with law enforcement agencies across the province, and there may be circumstances where information is shared during an investigation where we are permitted to do so under the legislation,” Greenfield added.
“Any matter that raises issues of physician criminal actions is reported to the police.”
No charges have been laid against Kumra, said OPP spokeswoman Carolle Dionne. Due to privacy legislation, she would not say if the OPP is investigating the doctor.
A 2016 report by Ontario’s auditor general called oversight of the physician billing system“weak,” and found serious issues, including that the ministry doesn’t even bother to go after a lot of doctors with suspicious billings because it is too resource-intensive.
Little has been done to improve the situation since a followup report came out in December 2018.
