Chapter 1: Medical Billing in Ontario
No matter what profession you’re in, billing can get complicated, so it’s no surprise that medical billing has been known to cause its fair share of headaches. It’s a lot to take in, there are various physician payment models that determine how you’re going to get paid, and depending on that, you need to understand how OHIP claims submission works, OHIP fee codes, deadlines and more. Don’t worry though, this chapter covers everything you need to know about Medical Billing in Ontario.
In this chapter:
1. Physician Payment Models
There are a variety of different physician payment models throughout Canada. Which one you’re on usually depends on
where you’re working and what payment model is used there. The 3 most popular options for physician payment models are:
1. Alternative Payment Plans (APP)
Increasingly popular are the various alternative payment plan (APP) models. They may also be referred to as “alternative funding plans” or “new payment models” in healthcare.
While they vary widely, APPs are generally made up of a combination of:
Fees for clinical services
Rewards for participation in specific clinical initiatives
Population or capitation funding
Payment for admin costs
Bonuses for achieving specific targets
If you receive a regular salary, then this is usually paid in 'time-based payments'. These can vary from simple annual salaries to shift stipends, sessional payments or hourly rates.
Doctors at an academic institution, community health centres or hospitals usually work under this model.
3. Fee For Service Model
About 70% of doctors in Canada work under a Fee for service model (FFS), with nearly 99% of physicians in Ontario annually bill some type of work under FFS. In a traditional fee for service model, a doctor is essentially a small business.
How does it work?
Basically, you submit 'invoices' of who you saw and what you did to the Ministry of Health, who then reimburses you for the health care services you’ve provided. This is all done through the Ontario Health Insurance Plan (OHIP). The general process is:
You see a patient
You fill out a claim using a specific code that explains what service you provided, Each code corresponds to a specific dollar amount.
You submit the claim to OHIP for payment
OHIP reviews the claim and reimburses you if they approve it
If you’re a GP and you see a patient for a visit you can submit a claim with the fee code A005 (Consultation). This fee code has a value of $77.20, which is how much OHIP would reimburse you for under the fee for service model.
For every claim you submit you need to make sure a diagnose code accompanies your billing code.
If you work at more than one place it’s quite common that you’ll intertwine between the different physician payment models.
2. Locum Tenens
Locum tenens are temporary substitutes that have been contracted to replace another physician who is on holiday, taking a leave of absence, or because a clinic/facility has an overflow of patients. Being a locum is similar to being a substitute teacher, you might be there for 1 day, 2 weeks or half a year!
Working as a locum can be a great opportunity if you’re just starting out, retired or looking for more free time. It’s becoming more and more popular as both a lifestyle and career choice.
Here are just some of the benefits of working as a locum:
You really have the opportunity to create your own schedule (you’re in demand so there’s no shortage of jobs).
You make more than any salaried doctor (we’re talking up to 20-40% more).
You get to experience different practices, different patients, and different colleagues. In general, you’ll have more of a variety of different experiences.
If this sounds like something you’d be interested in, find out more about the pros and cons of locum work and how to get started (like finding your perfect job and negotiating correctly)!
3. OHIP Schedule of Benefits
The OHIP Schedule of Benefits is the official document from the Ministry of Health that lists all the services that are insured under OHIP and how much each service pays. If you work under the fee for service model this is where you’ll find the billing and diagnostic codes with their descriptions, rules and dollar amounts.
At first glance, it can be overwhelming and confusing since it’s presented in an extremely long PDF (it’s almost 740 pages long), and lists more than 6,000 services. That being said, there is an electronic version of it in which separates codes by specialities and allows you to search for a code using only a keyword or a description.
Most medical billing software should provide you with a list of codes so you can just quickly choose which ones you’re looking for at the same time you’re sending your claim to OHIP. Otherwise, billing the correct codes becomes tedious and confusing as it’s almost impossible to search through the PDF on a day-to-day basis.
4. How are Claims Submitted? - MC EDT Ontario
When you’re working under the fee for service model you need to submit your claims to OHIP in order to get paid. OHIP claim submission works through an electronic data system known as the Medical Claims Electronic Data Transfer (MC EDT). It’s a secure web system that allows you or third-party software providers to submit claims to OHIP.
Important Note: This is the only system used to transfers claims to the Ontario Health ministry. In order to use it, you need to be an authorized user. Although you can submit claims manually yourself most doctors join an authorized software system in order to upload claims and download reports faster and easier. The exact instructions for setting up your account are found in Chapter 2.
In order to get reimbursed through OHIP claim submissions every claim you submit will need to include:
The patient’s information
(in order to make sure they’re eligible for insured services through OHIP)
a Fee Code and a Diagnostic Code
5. Payment: OHIP Cut-Off Dates
OHIP claim submissions run on a monthly cycle, and are based around the 18th of each month. The 18th is the deadline, known as the “cut-off date,” which means that any claims you submit up until the 18th of each month will be processed for payment by the 15th of the next month. When the 18th falls on a weekend or holiday, OHIP moves the cut-off date to the next business day.
Sometimes, claims received after the 18th of the month might still get processed by the end of the month, but to make you get paid on time we suggest submitting before 5pm on the 18th.
The best way you can remember the deadlines for MC EDT claim submissions is to download a shareable calendar of the OHIP Cut-Off Dates 2019/2020.
6. OHIP Remittance Advice (RA) Report
Around the 5th-7th of the month you receive a remittance advice (RA) Report and a Claim Error Report. These reports let you know, in detail, which claims have been approved, paid with adjustment, rejected or have errors that require specific changes in order to be paid.
RA Report Example:
How this report will look depends on who is submitting claims for you. Below is an example of what your RA report/active claim status would look like on Dr. Bill.
Now that you’ve got a better understanding of how medical billing in Ontario works you need to make sure you’re properly registered and authorized for OHIP claim submissions. Chapter 2 walks you through everything you need to do in order to start submitting claims to OHIP.