Learn Basic OHIP Billing

Chapter 2

Learn Basic OHIP Billing

Ultimate Guide to Medical Billing for New Doctors



A Bit Of Background On The OHIP Billing Process

The Ontario Health Insurance Program (“OHIP”) operates on the honour system. Ontario physicians submit claims for the insured services they provide to patients and are generally paid by OHIP without any confirmation or scrutiny.

The Ministry of Health and Long-Term Care (MOHLTC) works to provide an accounting mechanism to protect the public purse from potential fiscal abuse by the medical profession. This process is administered under the Health Insurance Act and Commitment to the Future of Medicare Act.

The legislation has long permitted the General Manager of OHIP to scrutinize physicians’ OHIP billings. However, the Auditor General has raised a concern that the Minister of Health and Long-Term Care was failing to hold physicians accountable for their OHIP billings, leading to a recent uptick in billings audits.

The Auditor General’s 2016 report (see here and here) criticized the Ministry for the emphasis placed on education of physicians who were inappropriately billing, rather than recovering the excessive billings.


The Basics of the OHIP Billing Process

  1. The physician sees and treats the patient.
  2. The physician chooses fee code and submits a claim to OHIP (through a billing software) that outlines service provided, along with the patient diagnosis.
  3. OHIP reviews the claim and provides reimbursement upon approval.

What You Need to Know about the OHIP Claims Submissions Process

  • Each service provided corresponds to a billing code and a respective dollar amount. The OHIP fee codes are set out in the OHIP schedule of benefits and fees.
  • Claims must be submitted through the billing software with the appropriate billing code and patient information.
  • The Ministry processes claims on an ‘honour system’ – the initial review of a claim is preliminary and not thorough.
  • Claims undergo a series of computerized checks and are generally processed as submitted to ensure prompt payment.
  • If necessary, claims are later audited through a post-payment review process.

What You Need to Know About OHIP’s Payment Schedule

OHIP’s posted cut-off for claim submissions is on the 18th of the month.  If the 18th falls on a weekend or holiday, the cut-off is the next business day. 

Often, claims submitted after the cut off are still processed for payment, but OHIP is not obligated to pay past the 18th.  Deposits are made the next month on the 10th business day, typically, the 14th of the month. For stable cash flow, keep in mind that each OHIP deposit will cover about four weeks of work.


Managing Your Billing Time Week-to-Week

With this process and timing in mind, how should you manage your billing time week-to-week? Below we’ve included our best recommendations.

How to manage the OHIP billing cycle for Ontario doctors
WeekRecommendations
1Your payment reports arrive early this week. Go into MDBilling.ca, download your reports and reconcile. You may need to resubmit claims, follow up with patients, etc. For more guidance, check out our DIY reconciliation manual.
2You should try and keep up with claims submissions daily. But if you have a backlog, spend this week submitting claims so that you can submit as many as possible prior to the 18th.
318th of every month: OHIP submission deadline. Everything submitted up until this point will be processed in the current payment cycle. And will show up in MDBilling.ca’s “Claims Summary Payment” for next month. All claims processed after this date will show in next month’s “Unprocessed Report” for next month. Continue submitting claims, reconciling any missing pieces from the last month.
4This week is your catch-up time. You’ll be getting rejections on an ongoing basis. (approximately 2 business days from submission) and you will get a notification by email. Aim to try to fix these rejections every week, but if you have a backlog, try to finish dealing with them this week. For more guidance, check out our OHIP error code library.

What You Need to Know About the OHIP Audit Process

If claim assessors notice a conflict or issue in medical billing, they can engage in post-payment review, or audit.  In Ontario, the Ministry of Health and Long-Term Care audit system is known as the Payment Integrity Program. Its primary goal is to educate and inform physicians about appropriate medical billing habits and protocols.

In some scenarios, the Canadian Medical Protective Association (CMPA) will engage legal experts and help with the audit process. This assistance usually extends to the end of the review process, but in special circumstances– when review committees commit a fundamental error in law, or obviously misinterpret the schedule of benefits–the CMPA will instruct legal counsel to appeal the decision of the paying agencies.

What Could Trigger A Billing Audit

Audits can be triggered when there is suspicion of:

  • Incorrect noting of type of treatment provided
  • Billing for services not rendered
  • Inappropriate claim of higher fee code
  • Fraudulent overbilling for insured services

What to Expect If You Get Audited

There are two general stages of the post-payment review/audit process.

Stage 1

  • If engaged in post-payment review, this stage is focused on education on proper billing protocols – i.e. educational letter to physician explaining the cause for concern.
  • Claims assessors will request further information and explanation about billing.
    • Specific patient records at issue may be requested.
    • Medical records must show:
      • Insured service was provided to an insured person;
      • Claim submitted represented the service provided; and
      • Service was medically necessary.
  • If the claim is determined to be improper, the Ministry will ask the physician to pay back previously paid submissions.

Stage 2

  • If a physician does not agree with the findings of post-payment review, disagreement will be escalated to the Physician Payment Review Board. Both sides can make submissions.
  • If the Ministry or Physician Payment Review Board determines that there was fraudulent activity, the Ministry can refer the case to the Risk Management and Fraud Control Unit of the Ministry of Health. This Unit will determine if the case warrants forwarding to the Ontario Provincial Police for criminal investigation.
  • The Ministry can also send the case to the College of Physicians and Surgeons of Ontario. This step can lead to sanctions and restrictions on the physician’s ability to practice:
    • Possible penalties
    • Fine
    • Reimbursement
    • Compensation and restitution
    • Publication of name; description of the situation
    • Imprisonment
    • Revocation of the licence to practice medicine

Medical Billing Do’s and Don’ts

Get familiar with our recommendations to build healthier medical billing processes in your practice – these are based on our experience and input from healthcare lawyer Lonny J. Rosen, C.S. of the law firm Rosen Sunshine LLP and MOH claim assessor, C. Sinclair.

DO

  • Document, document, document – understand appropriate billing and record-keeping requirements.
  • Recognize appropriate billing – justify the use of the fee code by documenting all components of the service. Seek advice if unsure of what code to bill before billing it.
  • Choose an experienced billing agent (with 7+ years experience).
  • Have a system in place for monitoring billings and conduct your own preventative audit of your billing records.
  • MRP premiums (E083/E084). Work it out with your colleagues or department head on who should be paid when there are two MRPs on the same day.
  • OHIP data is considered financial records. Keep it up to 7 years, as you could be audited.
  • Ensure that you and your billing agent are using approved billing software (listed on the MOHLTC website).
  • If audited, contact the CMPA or legal counsel.
  • Most importantly, get advice before responding to any inquiry.

DON’T

  • Bill special visit premiums excessively.
  • Submit just before the 6-month deadline. If the claim is rejected, you may end up resubmitting past the 6-month cut-off.
  • Forget to reconcile monthly to avoid claims being stale dated.
  • Just resubmit a claim where it is unclear why it was rejected. If you have a question about a claim, submit a RA inquiry and wait (it may take a few months).
  • Ignore a query from the Ministry or OHIP.
  • Try to justify the unjustifiable. If you billed the wrong code due to a mistake or misunderstanding, remedy that (but get advice first).
  • Double down. If you made a mistake, do not try to cover it up.
  • Destroy or delete medical records or change them after the fact. The only exception is if you need to note a late entry while maintaining the original entry.
  • Take the audit process lightly or delay in taking action.

Here’s a printable version of our OHIP billing do’s and don’ts that you can hang in your office or share with your team.


OHIP Billing Process Overview – Getting in a Billing Mindset

If this feels like a lot of new information, it is! Review this list to help orient yourself as you kick-off your own medical billing process.

  1. Review the OHIP schedule of benefits preamble and get a sense of how much codes are worth.
  2. Get a sense of how much you make per shift (efforts vs. earnings). MDBilling.ca reports can help with this.
  3. Bill, review, and then modify if necessary.
  4. Orient your month around the submission deadline (18th of the month), and the payment cycle (10th business day of the next month).
  5. Bill claims timely, as the stale date is 6 months from the date of service.
  6. If you must, start billing now and get your billing number later.
  7. Ask peers about the locums and codes they use.
  8. Ask colleagues about different rules and billing culture at each hospital.

Start Here

Should I find a lawyer?

In any cases of billing audits, physicians should contact the CMPA or a lawyer who has experience with OHIP billing matters for assistance.

Source: The legal recommendations above were provided by Lonny J. Rosen, C.S., Health Law Specialist. If you have additional questions, please contact Lonny at 416 572 4901 or by email at [email protected]