When a newborn passed away at a hospital in the Toronto area, Dr. Jane Healey faced a tough decision. The claim made to the Ontario Health Insurance Plan (OHIP) for the infant’s death was denied. Dr. Healey had to choose between forfeiting her payment or requesting the grieving parents to visit Service Ontario. The baby succumbed to a genetic ailment after ten days, as explained by Dr. Healey. Ultimately, she opted not to trouble the family.
Speaking to CBC Toronto, Dr. Healey expressed, “That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you.” She highlighted that this issue is not unique to her.
Billing problems with OHIP have emerged as a significant concern for physicians as they negotiate a new compensation agreement with the province. An arbitrator recently instructed both parties to find prompt solutions.
Health Minister Sylvia Jones’s spokesperson, Ema Popovic, mentioned that over 99% of claims are automatically paid upon submission, showcasing the system’s efficiency. 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 chairs the pediatrics section at the OMA, revealed that unresolved OHIP billings are often linked to complex procedures such as limb reattachment surgeries involving multiple physicians.
The ministry stated that two-thirds of claims requiring manual review are classified as “complex surgical claims” involving multiple procedures. This complexity can deter doctors from pursuing intricate and innovative medical work, suggested OMA president Dr. Zainab Abdurrahman.
The province’s manual review process is deemed suitable for complex surgical claims, with more than 95% of cases resolved within 30 days, according to Popovic. Doctors have the option to appeal the outcome.
The arbitrator has directed the province and the OMA to collaborate on solutions concerning good-faith payments and manual reviews for complex OHIP billing cases. The OMA is advocating for the reinstatement of the good-faith payment system, enabling doctors to invoice for patients without valid health cards, such as newborns and critically ill uninsured individuals.
Regarding the manual review process, which physicians claim can drag on for months for intricate OHIP invoices, the OMA is proposing the establishment of an OHIP ombudsman office staffed with clinical experts.
Dr. Abdurrahman emphasized the importance of having clinical expertise in the review process to avoid issues arising from inadequate matching. Popovic mentioned that physicians currently conduct the final review for more nuanced cases. The ministry is actively working on reducing administrative burdens for doctors through various initiatives and aims to modernize the billing system for improved efficiency.
Popovic expressed disappointment that the focus remains on less than one percent of claims requiring manual review, rather than acknowledging the collaborative progress made to support physicians. Failure to reach a resolution by the new year could lead to arbitration between the OMA and the province.