For a variety of reasons, claims sent to OHIP can be rejected or denied.  In the second part of this series we’ll look at claims that get rejected on the Remittance Advice report.

The last blog post in this series focused on claims rejected on error reports.  Unfortunately, claims that make it through that initial sweep may still go unpaid.  Here are some common examples of unpaid claims and how to prevent them or correct them.

E082s Paid to Another Physician

E082 is an MRP premium that is payable only once per hospital admission.  It’s meant for the physician who’s MRP and completes the admission assessment, but this often leads to conflict.  It could be the on-call Internist to the ER, the hospitalist who takes over care, or a different specialist who’s involved with the patient.  To complicate matters further, OHIP is not interested in getting involved in these disputes so they’ll generally pay it to the first doctor who submits it.  Once it’s paid to one physician, any other physician who bills it, even if they’ve billed it correctly, is out of luck.  It’s recommended that physicians discuss these internal billing issues with other relevant parties at the hospital and come up with a policy about who should be billing these codes so everyone is on the same page.  This will not stop all conflicts with E082s, but it will stop most of them.  Of the many hospitals we deal with, the ones that have had internal dialogue about these codes have, by far, the least number of issues.  Another way to limit or reduce these unpaid claims is to submit claims quickly.  The sooner the claim gets to OHIP, the more likely an E082 code will be paid.

Maximum Number of Services

Certain codes face restrictions.  For example, doctors are allowed no more than 10 special visit premiums to the ER in an evening shift (K994/K995).  If a doctor bills more than 10, these visits will be rejected by OHIP.  Another example involves MRP subsequent visits.  After a patient has been in the hospital for more than five weeks, MRP visits are limited to 3 per week.  At 9 weeks, subsequent visits are limited to six per month.  Any additional visits will be properly rejected by OHIP.  In these cases, there is no recourse and OHIP’s rejections are correct and consistent with the Schedule of Benefits.  It should be noted that there is the possibility of resubmitting rejected MRP codes as other billing codes if it’s allowable within the context of the Schedule of Benefits.  For instance, additional visits due to intercurrent illness (C121) may be payable in the place of these rejected MRP visits if the patient’s condition meets the definition of ‘intercurrent illness’.