skip to content

Uninsured Services: Billing And Block Fees Patient Information

Print page icon

The College of Physicians and Surgeons of Ontario (CPSO) is the organization that is responsible for licensing medical doctors and making sure your doctor is following the rules, and takes care of you in an ethical, professional and safe manner. The content on this page has been adapted from our Uninsured Services: Billing and Block Fees  policy. We’ve summarized it here to help you understand what you are entitled to and what to expect when your doctor charges you for uninsured services or offers you the option of paying a block fee.

Not all services doctors provide are insured services that are covered by the Ontario Health Insurance Plan (OHIP). Physicians are entitled to be paid for these uninsured services and may charge you a fee when providing them.

Insured services are paid for by OHIP. A doctor cannot charge you for these services or any element of the service which the government considers to be “constituent” or essential to it (e.g., making an appointment, making a referral to a specialist, reviewing your medical history etc.).Uninsured services are not covered by OHIP. This most commonly includes things like sick notes for work, copy and transfer of medical records, or prescription refills, but can also include medical procedures (e.g., elective cosmetic procedures). It also includes providing care to individuals who are not covered by OHIP.

Physicians who charge for uninsured services must ensure you are told what the service will cost before it is provided to you. Your physician’s office staff may be helpful in answering any questions you have about these fees, but your doctor must also be available to help if you’d like to speak to them.

Physicians cannot charge you in exchange for faster access to care

Physicians are not allowed to charge or accept payment for giving patients faster access to insured services. However, sometimes physicians will bundle insured services with uninsured services (providing them together) in a manner that leads to differences in when and how you access care. It can be hard to know the difference between being charged for access to insured services (which is not allowed) and legitimately being charged for uninsured services which comes with a difference in terms of access. If you’re at all concerned, ask your doctor what you’re paying for and why there are differences in access, contact the College’s Patient and Public Help Centre, or the government program that monitors these practices.

Fees for uninsured services must be reasonable

When charging patients for uninsured services, physicians are required to make sure that their fees are reasonable.

In deciding what is reasonable to charge, physicians will consider both the nature of the service they are providing (e.g., a sick note vs. a medical procedure) and their professional costs (e.g., the time involved, whether other staff will be involved, etc.). The Ontario Medical Association sets out recommended fees for common uninsured services and many physicians rely on these recommendations. You might have seen this list of fees posted in your doctor’s office.

CPSO also requires doctors to consider the financial burden that these fees may place on patients. If you’re concerned about your ability to pay for a service that you need, tell your doctor so they can consider whether it would be appropriate to reduce, waive, or allow for flexibility with respect to the fee. It won’t always be appropriate for doctors to adjust their fees, but knowing your situation will help them make this decision.

Paying for uninsured services

You can pay for uninsured services just as you would pay for most other services – you pay for them at the time the service is provided. This is often referred to as “pay-per-service.” However, sometimes doctors will offer patients the option of paying for uninsured services through a “block fee.”

A block fee is kind of like an insurance policy. You pay a flat fee up front that covers you for a set of uninsured services for a set amount of time. Block fees cannot be shorter than 3 months and cannot be longer than a year. If you need any of the included uninsured services during this time, they will be covered by the block fee, and you won’t have to pay separately for them. For some patients, this may be a more economical and/or convenient way to pay for uninsured services.

If you’re offered a block fee, you should consider whether choosing to pay it is in your interest. Think about whether you’ve needed uninsured services in the past and whether you might need any in the future and the costs associated with them.

When doctors offer you the option of paying a block fee, they:

MUST:
  • Offer the block fee to you in writing
  • Give you the option to choose between pay-for-service and a block fee
  • Indicate which services are covered, which (if any) are not, the fees that will be charged if you choose to pay-per-service, and a list of fees that are only reduced if you choose the block fee
  • Ensure you get answers to your questions and help making your decision if you need it, and be personally available to help if you ask
  • Give you a week to change your mind if you choose the block fee
MUST NOT:
  • Refuse to provide you care, refuse to accept you into their practice, or stop treating you altogether if you decline to pay the block fee
  • Offer to provide you faster access to care if you choose the block fee
  • Suggest that without payment of the block fee, services will be limited or reduced, or that quality of care will suffer in their practice
  • Include administrative or overhead costs associated with providing insured care in the block fee

Paying for missed appointments or last-minute cancellations

It’s important to know that when you miss an appointment or cancel at the last minute, you not only impact your doctor (e.g., they may lose income, they may incur costs, etc.), but you impact other patients who could have taken your appointment. To the extent that you can, it’s important to make sure you go to the appointments you’ve made or cancel them with enough notice that another patient can take your spot.

Your doctor can charge you a reasonable fee if you miss an appointment or cancel with less than 24 hours’ notice (or within a reasonable and agreed upon timeframe in a psychotherapy practice). CPSO requires doctors who intend to bill patients for missed or cancelled appointments to have a system in place that allows you to cancel, to have informed you in advance of their policy, and to have been available at the time of the appointment. If you have legitimate reasons for missing or canceling your appointment last minute, tell your doctor. We require doctors to consider granting exceptions in limited circumstances (e.g., first or isolated incident, intervening circumstances, etc.) and if you’re having difficulty paying the fee, explain this to your doctor so they can consider whether to adjust the fee on compassionate grounds.

For more information, please visit Uninsured Services: Billing and Block Fees, or call us at 1-800-268-7096 ext. 603