The monies ordered recovered, and the ledger you were never shown.

Start with the structure, because the structure is the whole premise. National estimates put the public share of physician spending at over 98 per cent, and the public share of hospital spending at roughly 90 per cent. Private insurance finances effectively none of physician services. So when a physician bills inappropriately in Canada, there is no parallel private payer absorbing part of the loss. The money comes from one pool, the provincial treasury, which funds care for everyone. This is a structural fact, not a political claim, and it is the correct foundation for everything that follows.

For scale: total health spending in Canada is projected at about $399 billion in 2025, roughly $9,626 per person, or 12.7 per cent of GDP. Hospitals are the single largest category at about 26 per cent. Physician services are roughly 13 to 14 per cent. The public and private split has been stable for two decades, with the private share around 30 per cent of the total and concentrated in drugs, dental, and vision, not in physician or hospital care. The figures here are CIHI National Health Expenditure estimates; the over-98-per-cent figure is the load-bearing one, and it rests on CIHI's own series.

The actors are specific. The Medical Services Branch within the Saskatchewan Ministry of Health administers physician payment, and its Policy, Governance and Audit Unit runs routine audits. The Joint Medical Professional Review Committee, the JMPRC, is a legislated physician peer-review committee, with two physicians appointed by each of the Saskatchewan Medical Association, the College of Physicians and Surgeons of Saskatchewan, and the Ministry of Health. The College receives referrals of potential inappropriate billing for possible disciplinary action.

The authority is statutory, not discretionary. The JMPRC reviews a physician's pattern of medical practice associated with billing. It can review a physician's billings over a 15-month period, request copies of medical records, and interview the physician. If the pattern is deemed unacceptable, the committee has legislative authority to order the physician to repay monies to the government. The payment authority and the definition of an insured service rest on The Saskatchewan Medical Care Insurance Act, subsection 14(1). The billing obligation is tied to The Medical Profession Act, 1981, section 46, and the College Code of Ethics. A physician who disagrees with a JMPRC decision has 30 days after the final order to appeal to the Court of King's Bench.

The receipts: monies ordered recovered

The Branch publishes a three-year summary of all monies ordered repaid by physicians because of inappropriate billings or an inappropriate pattern of practice. The fiscal year runs April 1 to March 31. The table is reproduced here from the payer's own bulletin, with no individuals named, because the record itself does not name them.

The routine-audit catalogue: what the unit checks

The Branch also publishes the specific routine audits its unit runs on a recurring basis. This is the second receipt: it names, at the code level, the exact mechanisms the payer reconciles. From the 2025 bulletin, the audits undertaken included:

• 5B + 110A/161Aa partial assessment billed alongside an injection service
• third-partypartial and complete assessments billed for uninsured third-party requests
• 815Amultiple surcharges billed in one day by the same doctor
• 769A / 762Aremote consultation codes where remote status and documentation must be verified
• 615Athe house-call surcharge
• 795Aprescription renewal by fax or email
• 64B–68BChronic Disease Management codes, flow-sheet and time-recording checks
• E / P / Tlocation-of-service premiums

Discipline noteEvery item above is a published audit target, not an allegation against any named physician. The register is "the payer documents this as a recurring inappropriate-billing pattern and audits for it," with the code and the source.

The patient is the one person present at the point of service, and is structurally the last person to ever see what was billed for it. That asymmetry is not an accident of culture. It is built into how claims are processed, and the payer's own professional association says so plainly.

That is the payer's own profession conceding that payment is not verification. Most Canadians never receive a statement showing the service code billed under their health number, the amount the province paid, or whether duplicate claims were submitted. The claim travels from physician to ministry to payment, with the patient never in the loop. Because the consumer never sees the transaction, citizen-generated complaints are rare and the issue stays diffuse.

So discovery does not come from the person who was in the room. It comes through audits, inspectors, payment reviews, and tips. In Ontario, the ministry's own materials note that a large share of audits originate from external sources such as public tips or regulatory notifications, with the rest data-driven. Saskatchewan's billing bulletins likewise note that investigations can be initiated through inquiries and complaints from physicians or the public, alongside routine audits.

When someone does look at the data, the outliers are stark. Reporting on the Ontario Auditor General's findings records extreme billing patterns: 82 physicians who reported working 24 or more hours in a single day, a diagnostic radiologist billing for 461 patients in a day, and an ophthalmologist billing $6.7 million in a year, roughly double the next-highest biller in that specialty.

Discipline noteThese figures describe billing patterns flagged by the oversight body, not adjudicated fraud. They are reported here as what the Auditor General's work surfaced, with no intent attached, and traced to that body rather than asserted independently.

Across the Saskatchewan and Ontario source material, the same vectors recur. Each one below is published payer guidance about what is not appropriately billable, or an audit target. None of it asserts that a given physician committed fraud.

• Upcoding.Billing a higher-paying code than the service supports: a more complex service recorded where a lesser one appears to have been performed.
• Unbundling or code substitution.Splitting one service into several codes, or substituting a higher one. Saskatchewan flags a full-thickness graft code billed with a tissue-expander implantation; inserting a commercial product is not a skin graft.
• Billing for services not rendered or not medically necessary.The core audit category: a service apparently not performed, or not required.
• Duplicate billing.The same service submitted more than once, or by multiple providers for one encounter. Saskatchewan example: a duplicate ultrasound where the second eye for comparison is not billable.
• Surcharge or premium stacking.Time-of-day, location, or special-call premiums billed without meeting their criteria. Multiple surcharges in a day; location and house-call premiums.
• Assessment-bundling onto procedures.Adding a partial assessment to a procedure that does not independently warrant it; routine suture removal should be billed as the procedure alone.
• Virtual or phone-call code misuse.Billing a virtual assessment for administrative contact. Notifying normal results, booking, triage, sick-note calls, and form completion are explicitly not billable; the code is for a genuine partial assessment, "not simply a telephone call."
• Prescription-renewal overuse.Renewal codes flagged as high-volume, inappropriately billed services. They cannot be billed as routine practice, to clarify dosages, or to comply reflexively with pharmacy-initiated faxes.

The schedule generates these vectors structurally, not by anyone's character. Most claims are paid automatically, so the schedule's edges are tested at scale before any human reviews them. Ontario's schedule runs to more than 5,000 codes, and more codes means more adjacent pairs where substitution or unbundling is possible. Premium logic layers time, location, and call codes on top of base codes, which is exactly what the routine-audit list targets. And the medical record is the only check: the audit is fundamentally a record-versus-code reconciliation, and where notes are thin, the code stands unchallenged until someone audits it.

The United States runs billing integrity as high-profile criminal and civil enforcement. Department of Justice False Claims Act settlements and judgments exceeded $6.8 billion in fiscal year 2025, the highest annual total in the statute's history, with about $5.7 billion from healthcare matters. The annual National Health Care Fraud Takedown is a publicized event; one 2025 takedown charged 324 defendants over $14.6 billion in alleged fraud. Whistleblower suits, where a private relator earns a share of the recovery, drive most of the money, a structural feature with no direct Canadian equivalent.

The two countries diverge for structural reasons, not cultural ones. The US has a financial-bounty architecture that creates private incentives to surface fraud and generates headline numbers; Canada's recovery runs through salaried administrative units and peer committees with no bounty, so it produces audit tables, not press conferences. US enforcement is routed through federal courts toward indictments; Saskatchewan routes through a peer committee toward recovery orders appealable to a civil court. US Medicare is one payer among many, with a federal trust fund whose depletion is a recurring flashpoint; Canadian provincial plans are the payer, and attacking their integrity can read as attacking the universal system itself. And US beneficiaries receive summary notices, so the transaction is at least partly visible, while Canadian patients generally see nothing, removing a whole channel of citizen-surfaced complaint.

So the honest version of the old suspicion is architectural, not motive. Canada's billing-integrity function is administrative and low-visibility by design: no bounty, no criminal venue by default, no patient-facing statement, recoveries published only in technical bulletins. That is enough to explain why it stays out of political debate, without assigning intent to anyone. Lead with the architecture, and let the reader draw the inference.

Discipline noteThe $6.8 billion US headline is not a yardstick for the JMPRC's $1.6 million recovery year. One is criminal-enforcement scale across a private-payer system; the other is administrative recovery inside a single public pool. Keeping them apart is the whole point.