Block Fees and Uninsured Services


Policy Number:#3-10
Policy Category: Administrative
Under Review: No
Approved by Council: September 2000
Reviewed and Updated: November 2004, May 2010
College Contact: Physician Advisory Service

Downloadable Version(s): Block Fees and Uninsured Services


Introduction

Patients may need some services that are not covered by the Ontario Health Insurance Plan (OHIP). Examples of these types of uninsured services include sick notes for work; copy and transfer of medical records; and prescription refills over the phone.

Physicians are entitled to charge patients for uninsured services, which take physician time and resources. To make it more economical and/or convenient for those patients who may use many uninsured services, physicians may offer patients a block fee.

The purpose of this policy is to set out the College’s expectations of physicians who charge for uninsured services and/or offer a block fee.

Principles

  1. The physician-patient relationship is based on trust, and as such, the patient must be confident the physician will put the needs of the patient first.
  2. Good communication is a fundamental component of a trusting physician-patient relationship.
  3. Patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship, or pose a barrier to accessing health care services.

Definitions

Insured services

Services listed in the Health Insurance Act and the Schedule of Benefits for which physicians will be compensated by OHIP, 1 provided that the service is being rendered to an insured person. 2

In many cases, an insured service is comprised of several constituent elements. Examples of constituent elements of an insured service include the referral of a patient to a specialist and the administrative processing for a new patient being accepted into a practice. 3

Uninsured services

Services provided by a physician to a patient which are not paid for by OHIP. This includes services provided to uninsured individuals.

Block fee

A block fee 4 is a flat fee charged for a predetermined set of uninsured services. This flat fee may also be called an ‘annual fee’ (if it covers a period of 12 months). 5

Policy

A physician cannot charge patients for insured services, including the constituent elements of these services. 6 However, a physician may charge a reasonable fee 7 for the performance of an uninsured service.

1. Charging for Uninsured Services: Individually or Block Fee

If physicians charge patients for uninsured services, they must make a list of fees 8 available to the patient. This list must be available regardless of whether the fee will be paid on an individual per service basis, or in the context of a block fee.

a. Reasonable Fees

Physicians must ensure that the fees charged for uninsured services are reasonable, whether the fee is charge individually for services, as provided, or is included as part of a block fee. 9 If physicians charge a block fee, the amount charged must be reasonable in relation to the services offered under the block fee.

Physicians should refer to the Ontario Medical Association document, Physician’s Guide to Third-Party & Other Uninsured Services, for the recommended schedule of fees. Physicians are obligated to let patients know if they will be charging more than this guide. 10

b. Limitations to Charging Fees 11

Physicians should be aware that there are several services listed in regulation 12 that a physician may not charge patients for. These include:

  • Services not performed (but a physician may charge for the cancellation of an appointment less than twenty-four hours before the appointment time, or in psychotherapy practice, in accordance with any reasonable written agreement with the patient). 13
  • An undertaking not to charge for a service or class of services. 14
  • An undertaking to be available to provide services to a patient. 15

2. Offering a Block Fee

Physicians may offer patients the option of paying for uninsured services by way of a block fee. A block fee may be a more convenient and/or economical way for physicians to administer fees for uninsured services, and for patients to pay for these services.

Physicians offering a block fee must ensure the fee covers a period of not less than three months and not more than 12 months.

a. Patient Choice

Physicians who charge for uninsured services are not required to offer the option of paying by block fee. However, those physicians who offer the option of payment for uninsured services through a block fee must also provide patients with the alternative of paying for each service individually at the time that it is provided.

To ensure patients are fully informed of their payment options for uninsured services, physicians who offer a block fee must:

  • Offer a block fee in writing, 16 indicating the services that are covered by the block fee and providing examples of those (if any) that are not, along with a list of fees 17 that will be charged individually for each service should the patient not select the block fee option.
  • Provide patients with a copy of this policy or the appended information sheet for patients. 18
  • Answer any questions patients may have about the physician’s billing policy and about any charges they do not understand.
  • Obtain written confirmation if the block fee option is chosen and maintain it as part of the patient’s medical record. 19

Patients must be given the opportunity to rescind the decision to pay block fees within a week of their original decision (in which case they would be required to pay for services individually, as provided).

b. Patient Access to Care

Patient decisions regarding payment for uninsured services must not affect their ability to access health care services. Physicians must not:

  • Require that patients pay a block fee before accessing an insured service.
  • Offer to or treat patients preferentially because they agree to pay a block fee.
  • Terminate a patient 20 or refuse to accept a new patient 21 because that individual chooses not to pay a block fee. 22

3. Use of Third Party Companies

Physicians may use third party companies to assist them to administer a block fee or payment for uninsured services. Any communication to patients should identify the fact that a third party was involved.

Third parties who are asked to administer block fees or payment for uninsured services are acting on the physician’s behalf. Physicians are responsible for ensuring these companies adhere to the same standards required of physicians.

Appendix: Patient Information Sheet

 


Endnotes

1 The services paid for by OHIP are set out in Section 11.2 of the Health Insurance Act and the Schedule of Benefits.

2 An insured person is entitled to insured services under the Health Insurance Act and its regulations.

3 For a complete list of the common and specific elements of insured services that are considered to be constituent elements of the insured medical services, see the preamble of the Ontario Ministry of Health and Long-Term Care, Schedule of Benefits: Physician Services under the Health Insurance Act.

4  Although section 1 (1) 23 of Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), lists “charging a block fee” as an act of professional misconduct, physicians are able to charge a block fee as this provision has been declared ultra vires in Szmuilowicz v. Ontario(Minister of Health) and is of no force and effect.

5 This does not prevent physicians from calling a flat fee charge for a predetermined set of uninsured services by another name (i.e., ‘Patient Supplemental Plan’), provided that it is not misleading.

6 A physician may charge patients for services if the physician opted out of OHIP prior to December 23, 2004; the patient is not eligible for OHIP insurance; or if the services are not insured services which would otherwise be paid for by OHIP.

7 For more information, refer to the ‘Reasonable Fees’ section of the policy.

8 Physicians cannot charge an administration fee if patients elect to pay per service.

9 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 21.

10 Physicians should be aware that it is professional misconduct to charge “a fee for a service that exceeds the fee set out in the then current schedule of fees published by the Ontario Medical Association without informing the patient, before the service is performed, of the excess amount that will be charged”, under section 22 of Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991).

11 Physicians should also be aware of other activities relating to fees which may constitute acts of professional misconduct under Ontario Regulation 856/93.

12 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991).

13 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 20

14 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 23.1

15 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s. 1(1) 23.2.

16 This can include e-communication; however, physicians must provide information to patients by other means (i.e., mailed letter) if their patient(s) do not have access to the internet. Physicians should be aware of the inherent risks in using e-communication with patients and refer to relevant privacy legislation, policies and guidelines for further direction.

17 Physicians cannot charge an administration fee if patients elect to pay per service.

18 If the physician does not provide the patient with a copy of this policy or information sheet, then he or she must inform patients how they may obtain a copy. Physicians can refer their patients to the CPSO for further information about the CPSO policy.

19 For more specific guidance on medical records requirements, refer to the College’s Medical Records policy.

20 For more specific guidance on ending the physician-patient relationship, refer to the College’s Ending the Physician-Patient Relationship policy.

21 For more specific guidance on accepting new patients, refer to the College’s Accepting New Patients policy.

22 Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5, s. 18 (2).

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