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Medical Billing (OHIP plus)

. Attallah v. College of Physicians and Surgeons of Ontario

In Attallah v. College of Physicians and Surgeons of Ontario (Div Ct, 2021) the Divisional Court usefully explained an example of the OHIP system from the patient's and the physician's perspective:
[5] OHIP is a publicly funded payment system for Ontario’s physicians. It operates as a trust-based “honour system,” with finite resources. As OHIP is a third-party payer, the “customer” does not receive a bill and is generally unaware of what services the physician bills for. When physicians receive a billing number from OHIP, they are provided with educational materials including the Schedule of Benefits, the document that establishes how much physicians are paid for their services. Physicians are expected to familiarize themselves with the billing codes that pertain to their practice and to stay informed of periodic update bulletins from the Ministry regarding billing. When the Appellant applied for his billing number, he signed an acknowledgment of his responsibility to have read and understood the Schedule of Benefits and other relevant documents. As well, he acknowledged that he bore sole responsibility for complying with the Schedule of Benefits and for the veracity of his OHIP claims.

[6] Only two categories of billing codes used by family physicians are at issue in this case: “A” codes, which are assessment codes; and “K” codes, which are counselling codes. Unlike most OHIP codes, K codes are time-based. They are billed in units requiring a minimum amount of time spent in direct contact with the patient: one unit is at least 20 minutes; two units is 46 minutes; and three units is 76 minutes. All insured services have “constituent and common elements” which are included in the service a physician is paid for. For both K and A codes, this includes “obtaining and reviewing information from any appropriate source”, including the patient’s representative. Further, “assessments” include “discussion with … the patient’s representative … on matters related to the service.”

[7] Physicians cannot claim both a K code and an A code for the same patient on the same day (subject to certain exceptions); if they do, their billings will be automatically rejected.

[8] The A codes and three of the K codes at issue involve care provided directly to a patient. Other K codes in issue, in particular K002, involves an interview with a patient’s relative, rather than care provided directly to the patient. This service can be billed in the limited circumstance where a physician conducts an interview with a relative or other person authorized to make a treatment decision on the patient’s behalf, for a purpose other than to obtain consent. The Schedule of Benefits states that this applies to “situations where medically necessary information cannot be obtained from or given to the patient or guardian, e.g. because of illness, incompetence, etc.” It cannot be billed for “inquiry, discussion or provision of advice or information … to a patient’s relative or representative that would ordinarily constitute part of an assessment.” The interview must be booked as a separate appointment lasting at least 20 minutes. It must be billed to the OHIP number of the patient, not the family member. It cannot be billed on the same day as an assessment of the patient: if both a K002 and an assessment are billed for a patient on the same day, the K002 bill will be rejected.
. 1582235 Ontario Limited v. Ontario

In 1582235 Ontario Limited v. Ontario (Ont CA, 2020) the Divisional Court canvassed Ontario's regime for paying medical professions under the Health Insurance Act and the Independent Health Facilities Act, which had recently been amended:
[11] Medical services performed by physicians in Ontario are generally funded on a fee-for-service model. Under this model, physicians submit billing claims for insured medical services to the General Manager of the Ontario Health Insurance Plan (“OHIP”). OHIP will then pay the physician a professional fee for each service according to the fee codes set out in a Schedule of Benefits and Fees. This funding regime is governed by the HIA and its regulations.

[12] Funding for IHFs is governed by a separate statute, the IHFA. IHFs may charge “facility fees” to the Ministry on a fee-for-service basis in respect of overhead or operating costs and services that support the provision of the insured medical service. By way of example, if a radiologist reviews an ultrasound, a professional fee may be billed to OHIP for that insured service. Additionally, the IHF where the ultrasound image was generated will be entitled to charge a separate facility fee associated with that service. This latter fee, the facility fee, is meant to cover, amongst other things, the cost of the equipment and having a technologist produce the ultrasound image.

[13] Pursuant to the IHFA, the licensing process for IHFs is overseen by the Director of Independent Health Facilities (the “Director”) in the Ministry.


Legislative Amendments

[17] As previously noted, in December 2019, the HIA and the IHFA were amended. Amongst other things, the amendments replaced the PPRB with the HSARB in the HIA. The new IHFA now also expressly authorizes the Ministry to form an opinion on the overbilling of facility fees, which immediately gives rise to debt for which the Ministry can engage in set-off. After the Ministry has formed this opinion, a licensee can, pursuant to the IHFA, request a hearing before the HSARB.


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