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Uninsured Services: Billing and Block Fees

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Approved by Council: November 2017
Reviewed and Updated: May 2010, November 2004, September 2000

Companion Resources:

Other References:

 

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

 

Definitions

Insured services: Services, including their constituent elements, listed in the Health Insurance Act and the Schedule of Benefits that are publicly funded under the Ontario Health Insurance Plan1 (OHIP), on the condition that the service is being provided to an insured person2.

Uninsured services: Services provided by physicians that are not publicly funded under OHIP (e.g., prescription refills over the phone, copy or transfer of medical records, etc.). This includes services provided to individuals not insured under OHIP.3

Block fee: A fee that is charged to patients to pay for the provision of one or more uninsured services from a predetermined set of services during a predetermined period of time.4 At the time of payment it will not be possible for the patient to know how many, if any, services will be needed.5

 

Policy

  1. Physicians must not charge:
    1. for the provision of insured services (including the constituent elements of insured services),6
    2. any amount in excess to what OHIP has paid or will pay,7
    3. for services not performed,8
    4. for an undertaking to be available to provide services to a patient,9 or
    5. for uninsured services where the government has agreed to remunerate physicians for the provision of these services.10
  2. Physicians are entitled to charge for the provision of uninsured services, but must do so in accordance with this policy, other relevant policies, and relevant legislation.11

Setting Fees that are Reasonable

  1. Physicians must ensure that the fees they charge for uninsured services, including block fees, and appointments that are missed or cancelled without the required notice, are reasonable.12 In doing so physicians must:
    1. ensure that fees for individual uninsured services are commensurate with the nature of the services provided and the physicians professional costs, giving consideration to the recommended fees set out in the Ontario Medical Association’s Physicians Guide to Uninsured Services (“the OMA Guide”) and any recommended fees set out by professional specialty association(s);
    2. ensure that the amount charged for a block fee is reasonable in relation to the services and the period of time covered by the block fee; and
    3. when setting fees for appointments that are missed or cancelled without the required notice, consider what would constitute reasonable cost recovery and what would act as a reasonable deterrent to patients, recognizing the lost opportunity costs to other patients when appointments are missed or cancelled without the required notice.
  2. Physicians must also consider the patient’s ability to pay13 when charging for uninsured services, individually or by block fee, charging for appointments that are missed or cancelled without the required notice, and collecting outstanding balances. In particular, physicians must consider:
    1. the financial burden that these fees might place on the patient and whether it would be appropriate to reduce, waive, or allow for flexibility on compassionate grounds; and
    2. granting exceptions for appointments that are missed or cancelled without the required notice when it is reasonable to do so (e.g., first or isolated incident, intervening circumstances, etc.).

Communicating Fees

  1. Physicians must ensure that the patient or third party14 is directly informed of any fee that will be charged prior to providing an uninsured service, except in the case of emergency care where it is impossible or impractical to do so.
  2. Prior to providing an uninsured service, physicians must also notify the patient or third party if they charge more than the OMA Guide and the excess amount that will be charged.15
  3. While physicians may rely on staff to provide information about fees and to answer questions, physicians must be available to offer explanations and/or answer questions about their fees.
  4. Physicians are advised to:
    1. support patient education by posting a general notice in their office listing fees for common uninsured services (although this is not a substitute for directly informing patients or third parties of the fees associated with uninsured services), and
    2. direct patients to the College’s Patient Information Sheet on Uninsured Services: Billing and Block Fees.

Charging for Missed or Cancelled Appointments

  1. Physicians are permitted to charge for an appointment that is missed or cancelled with less than 24 hours’ notice (or in a psychotherapy practice, in accordance with any reasonable written agreement with the patient).16 Physicians who intend to charge patients in these circumstances must:
    1. have a system in place to facilitate the cancellation process,
    2. ensure the patient was informed of the cancellation policy and fees in advance, and
    3. have been available to see the patient at the time of the appointment.

Providing an Invoice

  1. Physicians are advised to always provide an itemized invoice for any uninsured services that are provided and for which fees are paid,17 but must provide an invoice when asked for one.18

Combining Insured and Uninsured Services

  1. Physicians who propose or provide insured and uninsured services together or offer uninsured services as an alternative or as a complement to insured services must:
    1. clearly communicate which services or elements of a service are associated with a fee and which are not;
    2. describe the differences between the insured and uninsured options in a clear and impartial manner, providing clear and unbiased information about the options available to the patient;19
    3. ensure that if their practice structure leads to different wait times for the insured and uninsured services they provide, they are compliant with Commitment to the Future of Medicare Act, 2004 prohibitions relating to preferential access to insured services; 20 and
    4. place the interests of their patients above their own by managing any real or perceived conflicts of interest that might arise in this context, including not referring a patient to a facility in which they or a member of their family has a financial interest without first disclosing that fact, and selling or otherwise supplying any medical appliance or medical product to a patient at a profit.21

Collecting Fees and Outstanding Balances

  1. Physicians may take action<22 to collect any outstanding fees owed to them, but must do so in a professional manner and in accordance with privacy legislation.23
  2. Physicians who are considering ending the physician-patient relationship due to an outstanding balance must comply with the expectations set out in the Ending the Physician-Patient Relationship

Offering a Block Fee

  1. A block fee may not be appropriate in all practice settings. As such, physicians must consider the nature of their practice and specialty before offering a block fee.24
  2. Physician must not charge a block fee in order to cover administrative or overhead costs associated with providing insured services.25
  3. Physicians must ensure the block fee covers a period of not less than 3 months and not more than 12 months.
  4. Physicians offering a block fee must always provide the patient with the option of paying for each service individually and must ensure that patient decisions regarding whether to pay a block fee do not affect their ability or the ability other patients in the practice to access health-care services. In particular, physicians must not:
    1. require that patients pay a block fee before accessing an insured or uninsured service,26
    2. treat or offer to treat patients preferentially because they agree to pay a block fee, or
    3. terminate a patient or refuse to accept a new patient because that individual chooses not to pay a block fee.27
  5. To facilitate patient choice, physicians must:
    1. offer a block fee in writing and in so doing:
      1. indicate that payment of a block fee is optional and that patients may choose to pay for uninsured services as they are provided;
      2. indicate that the patient’s decision to pay for uninsured services individually or through a block fee will not affect their ability to access health-care services;
      3. identify those services that are covered by the block fee, provide a list of fees that will be charged for each service should the block fee option not be selected, provide examples of those services (if any) that are not covered, and indicate for which services (if any) the fee is simply reduced if the block fee option is selected;
      4. use plain language and give consideration as to how to address language and/or communication barriers that may impede patients’ ability to understand what is being offered;
      5. refrain from using language that is or could be perceived as coercive or suggestive that without payment of the block fee, services will be limited or reduced, or that quality of care may suffer;
      6. invite patients to consider whether payment of a block fee is in their best interest given their needs or usage of uninsured services; and
      7. direct patients to the College’s Patient Information Sheet on Uninsured Services: Billing and Block Fees;28
    2. ensure that patient questions about the block fee are answered, ensure that help is available to patients to determine if the block fee is in their best interest, and be available to answer questions or provide assistance upon request; and
    3. obtain written confirmation if the block fee option is chosen and maintain it as part of the patient’s medical record.
  1. Physicians must give patients the opportunity to rescind their decision to pay a block fee within a week of the original decision. If the patient does rescind their decision, physicians must refund the amount charged for the block fee before then charging the patient individually for any uninsured services already provided.
  2. If the physician-patient relationship ends, physicians are advised to consider whether it would be reasonable to refund a portion of the block fee, considering both the time remaining and the services provided to date.

Using Third Party Companies

  1. Physicians using a third party to administer and manage their block fee or payment for uninsured services, must ensure that:
    1. any communication between the third party and patients identifies the third party by name and indicates they are acting on the physicians behalf; and
    2. the third party adheres to the same standards required of physicians, including this policy, other relevant policies, and relevant legislation.
 

Endnotes

1. The services paid for by the Ontario Health Insurance Plan (OHIP) are set out in Section 11.2 of the Health Insurance Act, R.S.O. 1990, c. H.6 (hereinafter, Health Insurance Act) and the Schedule of Benefits: Physicians Services under the Health Insurance Act (hereinafter, Schedule of Benefits).

2. An insured person is entitled to insured services as per provincial legislation and regulations. In Ontario the Health Insurance Act and its regulations set out the definition of insured persons who are covered by OHIP. The College acknowledges that individuals not covered by OHIP may be covered by other publicly funded insurance programs or by another provincial health insurance plan. As there are unique requirements, processes, and challenges related to each of these situations, for the purposes of this policy, the definitions of insured and uninsured services or persons are framed in relation to the Health Insurance Act and OHIP.

3. See the Schedule of Benefits, Section 24 of the General R.R.O 1990, Regulation 552 enacted under the Health Insurance Act, as well as the Ontario Medical Association’s Physician’s Guide to Uninsured Services for more information about the specific services that are or are not covered by OHIP.

4. This does not prevent physicians from calling the fee by another name (i.e., Patient Supplemental Plan, Block Billing Plan, etc.), provided that it is not misleading.

5. Adapted from Section 18(4) paragraph (a) of the Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5 (hereinafter, CFMA, 2004).

6. See the “Constituent and Common Elements of Insured Services” of the Schedule of Benefits and Sections 10(1) and (3) of the CFMA, 2004.

7. See Sections 10(1) and (3) of the CFMA, 2004 as well as Sections 18 and 19 of the Canada Health Act, R.S.C., 1985, c. C-6.

8. Section 1(1) paragraph 20 of the Professional Misconduct, O. Reg. 856/93 enacted under the Medicine Act, 1991, S.O. 1991, C.30 (hereinafter, Professional Misconduct Regulation), although see the “Charging for Missed or Cancelled Appointments” section of this policy for more information.

9. Section 1(1) paragraph 23.2 of the Professional Misconduct Regulation.

10. For example, while telemedicine is an uninsured service, the government has agreed to remunerate physicians providing telemedicine via the Ontario Telemedicine Network. Similarly, the Ontario Fertility Program remunerates physicians for some fertility services that are uninsured services.

11. This includes but is not limited to the College’s Medical Records and Third Party Reports policies as well as, the Health Insurance Act, the Professional Misconduct Regulation, and the CFMA, 2004.

12. It is an act of professional misconduct to charge a fee that is excessive in relation to the services provided (See Section 1(1) paragraph 21 of the Professional Misconduct Regulation).

13. The Canadian Medical Association Code of Ethics #16 states that “In determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with the patient.”

14. For example, a representative from an insurance company or a lawyer. For more information see the College’s Third Party Reports policy.

15. Section 1(1) paragraph 22 of the Professional Misconduct Regulation.

16. Section 1(1) paragraph 20 of the Professional Misconduct Regulation.

17. This would include any fees charged for missed or cancelled appointments and fees that are charged to patients who have chosen to pay a block fee, but where the fees for some services are merely reduced as a result.

18. It is an act of professional misconduct to fail to provide an itemized invoice when asked (See section 1(1) paragraph 24 of the Professional Misconduct Regulation).

19. It is an act of professional misconduct to make a misrepresentation respecting a remedy, treatment or device or to make a claim respecting the utility of a remedy, treatment, device or procedure other than a claim which can be supported by reasonable professional opinion (Section 1(1) paragraphs 13 and 14 of the Professional Misconduct Regulation).

20. Section 17(1) of the CFMA, 2004.

21. See sections 17(1) and 16(d) of General Regulation, Part IV, Conflicts of Interest, O. Reg. 114/94 enacted under the Medicine Act, 1991, S.O. 1991, C.30.

22. This may include physicians or their office staff contacting patients or hiring a third party (i.e., collection agency) to assist in the process.

23. This includes, for example, the Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A.

24. Although section 1(1) paragraph 23 of the Professional Misconduct Regulation lists “charging a block fee” as an act of professional misconduct, physicians are able to charge a block fee as this provision has been struck down by the courts in Szmuilowicz v. Ontario (Minister of Health), 1995 CanLII 10676 (ON SC) and is therefore not in effect.

25. See the “Constituent and Common Elements of Insured Services” of the Schedule of Benefits, read in conjunction with section 37.1 (1) of R.R.O 1990, Reg. 552 General, enacted under the Health Insurance Act and Section 10 of the CFMA, 2004.

26. Section 18(2) of the CFMA, 2004.

27. Section 18(2) of the CFMA, 2004. See as well the College’s Ending the Physician-Patient Relationship and Accepting New Patients policies.

28. For example, physicians can direct patients to the College’s website or refer patients to the College’s Public Advisory Service (1-800-268-7096 ext. 603).