Dr. Jane Healey faced a tough decision when a claim for a newborn who passed away at a hospital near Toronto was denied by OHIP. The infant succumbed to a genetic condition after 10 days, explained Healey. Ultimately, she opted not to burden the grieving family. “This means that we are not compensated for some of the very challenging, emotionally taxing tasks that leave a lasting impact,” she shared with CBC Toronto. Healey highlighted that she is not the only one facing such challenges.
Physicians are encountering difficulties with OHIP billing matters as they strive to finalize a new compensation agreement with the province. Recently, an arbitrator instructed both parties to swiftly devise solutions. Health Minister Sylvia Jones’s spokesperson, Ema Popovic, emphasized that over 99% of claims are automatically paid upon submission, indicating the system’s effectiveness. However, the Ontario Medical Association noted that out of over 200 million claims processed annually, approximately 1.16 million claims are rejected each year.
Dr. Healey, who also serves as the OMA’s pediatric section chair, pointed out instances where OHIP billings remain unresolved due to the complexity of procedures, such as limb reattachment surgeries involving multiple physicians. The ministry mentioned that when claims necessitate manual review, two-thirds are categorized as “complex surgical claims” involving multiple procedures. This complexity can deter doctors from pursuing intricate and innovative work, as stated by OMA President Dr. Zainab Abdurrahman.
The province’s manual review process, suitable for complex surgical claims, resolves over 95% of cases within 30 days, with provisions for doctors to appeal. An arbitrator recently directed the province and the OMA to collaborate on solutions regarding good-faith payments and the manual review process for complex OHIP billing cases. The OMA advocates for reinstating the good-faith payment system to allow invoicing for patients without valid health cards, like newborns and critically ill uninsured individuals.
Regarding the manual review process, which physicians claim can take months for complex OHIP invoices, the OMA proposes establishing an OHIP ombudsman office staffed with clinical experts. Dr. Abdurrahman highlighted that having non-clinical personnel reviewing detailed medical records poses challenges. The ministry affirmed that physicians conduct final reviews for intricate cases and is working on streamlining administrative tasks and modernizing the billing system.
Popovic expressed disappointment that the OMA focuses on the minimal percentage of claims requiring manual review, rather than acknowledging collaborative progress made to support physicians. If an agreement is not reached by the new year, both parties can return to arbitration, as outlined in the arbitration award.