When the OHIP claim for a newborn dying at a Toronto-area hospital was rejected, Dr. Jane Healey faced a difficult choice: forgo her pay or ask the grieving parents to go stand in line at Service Ontario.
The baby died of a genetic condition after 10 days, Healey said. In the end, she decided against bothering the family.
“That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you,” she told CBC Toronto.
And, Healey says she isn’t alone.
OHIP billing issues have become a sticking point for physicians as they work to finalize a new compensation deal with the province. Last month, an arbitrator directed the two sides to come up with solutions quickly.
Over 99 per cent of claims are paid automatically as submitted, “reflecting the system’s productivity,” said Health Minister Sylvia Jones’s spokesperson, Ema Popovic.
That’s true, the Ontario Medical Association acknowledges. But there are over 200 million claims that get processed every year — meaning about 1.16 million claims are rejected annually.
Healey, who is also the OMA’s section chair of pediatrics, says she and her colleagues have seen OHIP billings not be resolved because some procedures, like surgeries to reattach limbs, are too complex or involve multiple physicians.
Of the claims that don’t get paid automatically and are sent for a manual review, the ministry said two-thirds are categorized as “complex surgical claims,” where there are multiple procedures performed.
That can prevent doctors from wanting to do more complicated, innovative work, according to OMA president Dr. Zainab Abdurrahman.
“They’re thinking, ‘wow, I’m just going to have to be fighting to prove that I already did this work,’” she said.
“So, we’re also potentially stifling innovation within the province.”
Popovic said the province’s manual review process is “fitting” for complex surgical claims, noting more than 95 per cent of cases are resolved within 30 days and doctors can appeal the outcome.
Doctors, ministry directed to agree on solutions
An arbitrator recently directed both the province and the OMA to come up with solutions around good-faith payments and the manual review process in cases with complex OHIP billing.
The OMA has been pushing for the revival of the good-faith payment system, which would let doctors invoice for patients who don’t have a valid health card, like newborn babies, as well as for people in critical condition who do not have insurance.
When it comes to the manual review process — the one physicians say can take months, kicking in when an OHIP invoice is too complex to process automatically — the OMA is asking for the creation of an OHIP ombudsman office staffed with clinical experts.
Ontario is looking to expand what health-care professionals can do — from pharmacists prescribing more medications, to new roles for optometrists, psychologists and dental hygienists.
“Having people who are reviewing operating room notes or various physicians’ technical notes who don’t have clinical expertise, that isn’t matching up. So that’s causing issues,” said Abdurrahman.
Currently, physicians do conduct the final review for more nuanced cases, Popovic told CBC Toronto.
She said the ministry is already working to reduce administrative work for doctors through other initiatives, and that the government is continuing “to work with the OMA to modernize the billing system to make it even more efficient.”
It’s “disappointing” that the OMA is focusing on less than one per cent of claims that require a manual review “rather than highlighting the real progress we’ve made together to support physicians,” Popovic said.
If the OMA and the province can’t reach a resolution by the new year, they can go back to arbitration, according to a copy of the arbitration award.
