Physician OHIP billing

Physicians beginning to bill OHIP on a fee-for-service basis for the first time face a daunting task.  In addition to managing their patient encounters, they also have to worry about whether they’re billing the correct codes and whether their claims accurately reflect the services they provide. At JCL we’ve been lucky to work with hundreds of physicians, many of whom have been new to the world of OHIP billing.  Due to our years of experience, we’ve learned a lot about the types of questions new physicians have and the areas that concern them most. In fielding their questions, we find ourselves saying the same things over and over again. Here are three pieces of advice that every doctor new to the world of OHIP billing should know.


1) Read the General Preamble

The most important part of the Schedule of Benefits for physicians is the General Preamble (pages GP 1-72 in the Schedule, right at the beginning).  It lays out the definitions and rules that all doctors must know to bill OHIP properly … and optimally. The General Preamble can help if:

  • You want to know whether to bill a medical specific assessment or complex medical specific assessment
  • You need to know how many units to bill for a 37-minute in-patient case conference
  • You want to determine whether you’re providing an admissions assessment
  • You aren’t sure whether you can bill travel premium or not

The General Preamble is definitely not the kind of document that should be read once and then forgotten. It’s a resource that should be nearby whenever a physician is sitting down to work on their billing. And it’s also not a document that has ‘all’ the answers. There are plenty of confusing and inconsistent sections in the Schedule of Benefits, including the General Preamble. But without a doubt, all doctors who bill OHIP for their services should read it, think about it, read it again, and then refer to it regularly.


2) Keep Detailed Patient Notes

Once a physician reads the General Preamble, they’ll see that the Ministry of Health requires certain elements for a service to be payable. The most important of these is keeping accurate written records that support the billing codes you’re submitting.


For example, specialists can bill for an e-assessment but only if certain record keeping requirements are met.  Specifically, the following elements must be included in the patient’s permanent record:

  • the patient’s name and health number

  • name of primary care physician or nurse practitioner

  • date of request and reason of request

  • opinion, diagnosis, advice and/or recommendations provided by the specialist

If a specialist bills an e-assessment and these items aren’t noted, it’s not a payable service.  


So, the second piece of advice we have for physicians is to make sure they’re aware of the specific note taking requirements of the codes they are billing, and to keep detailed records of these.  The Ministry of Health can request patient records to verify billing, and will check these in the case of a billing audit.  Make sure the notes you take include what they need to include!


3) Get Organized

Billing OHIP for the first time is always a challenge, but the process can be notably less difficult for physicians who have developed a good way of keeping track of the work they do. If you’ve finished a week of MRP work in a hospital, it’s probably not a good idea to sit down at the end of the week and try to remember all the patients you saw and all the services you provided. Not only will you need to look up information after the fact (admit dates, referring physicians), which can be time consuming, but you will likely forget some of the less memorable items like the forms you completed or the minor procedures you may have performed. It’s a great idea to develop a billing sheet that organizes the information you will need for claims submission. If you work with a billing company like JCL, billing sheets help structure the data required so that nothing is missing, simplifying the process. This allows claims to be sent to the Ministry accurately and without delay, leading to faster payment.  A win-win.  

These three pieces of advice – reading the General Preamble, taking good patient records, and having an organized way of keeping track of your billing – will go a long way toward making the OHIP billing process go more smoothly.  We’re not saying that this will make billing “easy”, but it will certainly make it more manageable and allow you to focus more on your patients and less on administration.

Want to know more about your options for OHIP billing?

Click here to read “New Doctor? You have options”