Monday, May 29, 2006

OMA Physician's Guide to Third Party and Other Uninsured Services : January 2005

From: www.oma.org/Practice/Tools/ThirdPartyGuide.pdf

ONTARIO MEDICAL ASSOCIATION
PHYSICIAN’S GUIDE TO THIRD
PARTY AND OTHER UNINSURED
SERVICES
January 2005 Edition
TABLE OF CONTENTS
I. Definition of Uninsured Services ...........................................................................................2
1. At Physician's Cost ............................................................................................................2
2. On An Independent Consideration (I.C.) Basis .................................................................3
II. Third-Party Services .............................................................................................................4
III. Calculating Fees for Third-Party and Other Uninsured Services...................................7
1. Consultations and Visits ....................................................................................................8
2. Other Relevant Uninsured Services...................................................................................8
3. Immunization as an Uninsured Service .............................................................................8
4. Recommended Fee Charges For Photocopying and/or Transfer Of Medical Records.....9
5. Uninsured Report Forms .................................................................................................10
6. Unremunerated Report Forms.........................................................................................11
7. Canada Pension Plan (CPP) Forms................................................................................12
8. Life and Health Insurance Uninsured Report Fees .........................................................12
9. Establishing An Hourly Rate ...........................................................................................14
10. Block and Annual Fees ....................................................................................................15
11. Reports Requested by Employers and Other Issues Related to Workers’ Compensation16
IV. The Application of GST to Uninsured Services - Some Guidelines...............................17
1. Advance GST Rulings versus GST Application Rulings ..................................................17
2. GST and Block/Annual Fees ............................................................................................17
3. GST and Medical Legal Reports......................................................................................17
4. GST and Independent Medical Evaluations (IME)..........................................................18
5. GST and Insurance Forms...............................................................................................18
6. GST and Other Uninsured Services.................................................................................19
V. The Preparation of Medical Legal Reports .......................................................................19
1. Confidentiality .................................................................................................................20
2. Code of Ethics..................................................................................................................20
VI. Physicians as Expert Witnesses.........................................................................................20
1. Non-Treating (Retained) Physicians ...............................................................................20
2. Treating Physicians .........................................................................................................22
VII. The Direct Billing Process................................................................................................22
1. Some Practical Guidelines...............................................................................................23
2. Keeping Patients Well-Informed......................................................................................23
3. Charging Interest on Unpaid Accounts - Some Guidelines.............................................24
VIII. Collecting Unpaid Charges - The Small Claims Court System ..................................24
IX. Useful Websites....................................................................................................................25
X. Useful Telephone Numbers ..................................................................................................25
Appendix I: Sample Letter........................................................................................................27
Appendix II: Poster ...................................................................................................................28
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PHYSICIAN’S GUIDE TO THIRD PARTY
AND OTHER UNINSURED SERVICES
January 2005 Edition
Introduction:
The following physician guide provides a brief outline of uninsured services and suggested
fees, with particular attention to third-party services. This guide is intended to offer
assistance in establishing appropriate billing rates. However, physicians should use their
discretion on whether or not to charge above or below these suggested rates.
Please note that the majority of the information provided to physicians in this guide, unless
otherwise specifically noted, does not apply to WSIB Claims and requested Reports which
are captured under the Workplace Safety and Insurance Act 1996 - formerly the WCB Act.
I. Definition of Uninsured Services
Uninsured medical services are not covered by the Ontario Health Insurance Plan (OHIP)
and may be charged directly to patient at the discretion of the physician. Physicians should,
whenever possible, inform the patient or the person financially responsible about such
charges prior to treatment and should make an appropriate record (as required) of the
uninsured services they provide.
The following is a list of uninsured services that are commonly charged by physicians at
present time. The list is not exhaustive. For additional information, please refer to
Appendix A, B and D of the Ministry of Health’s Schedule of Benefits.
1. At Physician's Cost
This is defined as the actual, direct or invoice cost (including applicable taxes) incurred by
the physician, plus a reasonable mark-up to account for secretarial and other indirect costs.
(a) Preparation and transfer of an insured person's health records when this is done
because the care of the person is being transferred at the request of the person or
person's representative. In addition to the office overhead, the physician may charge
for his or her time in preparing the information for transfer.
(b) Toll charges for long-distance telephone calls.
(c) Preparing or providing a device that is not implanted by means of an incision and
that is used for therapeutic purposes, e.g. an I.U.D. Exceptions to this are if the
device is used to permit or facilitate a procedure or examination, or if the device is a
cast for which there is a fee listed in the Schedule of Benefits, in which case the
patient cannot be charged a fee.
(d) The costs associated with the application of fibreglass casts outside hospital.
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(e) Preparing or providing:
i. a drug, antigen, antiserum or other substances used for treatment that is not
used to facilitate a procedure or examination;
ii. a drug to promote ovulation.
2. On An Independent Consideration (I.C.) Basis
Independent consideration is defined as an acceptable professional rate, taking into account
factors noted in Section III of this Guide. Examples include:
(a) Missed appointments or procedures if less than twenty- four hours notice of
cancellation has been given by the patient. An exception to the twenty- four hour
notice exists for psychotherapy practices where a reasonable written agreement exists
between the patient and the physician.
(b) A service that is solely for the purpose of altering or restoring appearance, except
where the service is specifically listed as an insured service or part of an insured
service in the Schedule of Benefits.
(c) Advice given by telephone to an insured person at the request of the person or the
person's representative unless advice by telephone is specifically listed as an insured
service or part of an insured service in the Schedule of Benefits, such as G271 anticoagulant
supervision and G382 supervision of chemotherapy.
(d) Providing a prescription to an insured person if the person or the person’s personal
representative requests the prescription and no concomitant insured service is
provided.
(e) Travelling to visit an insured person outside the usual area of medical practice,
which is defined by the Ontario Medical Association as the greatest of eight (8)
kilometres or fifteen (15) minutes of travel.
(f) An interview or case conference in respect of an insured person that lasts more than
20 minutes and includes a professional none of whose services are insured services.
(g) An anaesthetic service rendered by a physician in connection with a service
rendered by a practitioner that is provided outside a hospital, or in connection with a
dental service that is not insured, and is provided in a hospital involving only the
removal of impacted teeth.
(h) A service rendered to a person who is 20 or more years of age and less than 65
years of age that is rendered solely for the purpose of refraction.
(i) The fitting of contact lenses other than for:
i. aphakia;
ii. myopia greater than nine diopters;
iii. irregular astigmatism resulting from post corneal grafting or corneal
scarring from disease; or
iv. keratoconus.
(j) The fitting or evaluation of hearing aids and tinnitus maskers.
(k) Treatment for a medical condition that is generally accepted within Ontario as
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experimental.
(l) An acupuncture procedure.
(m) Circumcision, except if medically necessary.
(n) Reversal of sterilization.
(o) In vitro fertilization other than the first three treatment cycles of in vitro
fertilization that are intended to address infertility due to complete bilateral
anatomical fallopian tube blockage that did not result from sterilization.
(p) Destruction of hair follicles.
(q) Certain surface and sub-surface pathology (such as select trauma scars, keloids,
benign lesions, etc, see preamble of the Ministry of Health and Long Term Care
Schedule of Benefits, pages 2D to 8D).
(r) Sex re-assignment surgery.
(s) Psychological testing.
(t) Psychotherapy that is a requirement for the patient to obtain a diploma or degree or
to fulfil a course of study.
(u) Counselling, therapy or any other service rendered for the purpose of weight loss
for the benefit of a patient other than a patient,
i. who has a medical condition that is attributable to, or aggravated by excess
weight, or
ii. who suffers from obesity (defined as a person whose body mass index is
greater than 27) and whose obesity puts the patient at an increased risk of
developing a medical condition that is attributable to, or aggravated by,
excess weight.
(v) A service that is part of a group-screening program.
(w) An examination or procedure for the purpose of a research or survey program other
than an assessment that is necessary to determine if an insured person is suitable for
the program.
(x) A service or treatment, including immunization or the administration of any drug,
rendered to an insured person in connection with, and for the sole purpose of,
travelling to a country outside Canada.
II. Third-Party Services
The current regulations define third-party services as any service (including an annual health
exam) received by a patient, which in whole or in part is necessary for the production or
completion of a document or transmission of information to satisfy the requirements of a
party other than the patient.
A physician may charge the patient or the third party in the event that the physician is aware
that information provided to the patient during the medical assessment will be used by the
patient at a later date to complete a third party requested form. The physician should not bill
OHIP in this situation.
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Except where noted under Exemptions, the following third-party services are uninsured,
when the service or document relates to:
(a) Admission to, or continued attendance in, a day care, pre-school, school, community
college, university or other educational institution;
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service to enable a patient to return to day care or pre-school, if
in the opinion of the physician the service is medically necessary. Note that
the report produced from the service remains uninsured and is billable to the
patient or third party; and
􀂾 Providing a service, completing a document, or transmitting information that
is required as evidence of immunization status for admission or continued
attendance in day care or pre-school program or a school, community
college, university or other educational institution or program.
(b) Admission or continued attendance in a camp, recreational/athletic program,
association, or club;
(c) Application for, or the continuation of, insurance coverage (e.g. taking out a life,
disability or other insurance policy);
(d) Application for, or the continuation of, a license (e.g. pilot, driver's and other
licenses);
(e) Entering or maintaining a contract;
(f) An entitlement to benefits, including insurance benefits or benefits under a pension
plan (e.g. private or CPP disability benefits);
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service to enable a patient to receive disability or sickness
benefits, if in the opinion of the physician the service is medically
necessary. Note that the report produced from the service remains uninsured
and is billable to the patient or third party.
(g) Obtaining employment (e.g. pre-employment medical examinations) or maintaining
employment (e.g. annual/periodic medicals).
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service relating to a patient's fitness to continue employment, if
in the opinion of the physician the service is medically necessary. Note that
the report produced from the service remains uninsured and is billable to the
patient or third party.
(h) An absence from, or return to work;
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service relating to a patient's absence or return to work, if in the
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opinion of the physician the service is medically necessary. Note that the
report produced from the service remains uninsured and is billable to the
patient or third party.
(i) Legal proceedings;
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service relating to legal proceedings if in the opinion of the
physician the service is medically necessary. Note that the report produced
from the service remains uninsured and is billable to the patient or third
party;
􀂾 Providing an examination and producing or completing documents or
transmitting information under the Mental Health Act, or for the purpose of
an investigation of an alleged sexual assault in accordance with requirements
of the Ministry of the Attorney General and the Ministry of the Solicitor
General
(j) Required by legislation of any government or to receive anything under, or to satisfy
a condition under, any legislation or program of government;
Exemptions – (i.e., the services are insured and the appropriate visit fee can be billed
to OHIP):
􀂾 Providing a service and producing or completing a document, or transmitting
information that is:
i. Required to be admitted to (or receive health services in) a hospital or
nursing home or home under the Homes for the Aged and Rest Homes
Act, a home for mentally handicapped under the Retarded Persons Act, or
a charitable institution under the Charitable Institutions Act;
ii. Required in relation to an annual health exam of a patient resident in a
facility defined in i);
iii. Required to receive anything under a Ministry of Health and Long Term
Care administered program;
iv. Required to receive welfare/social assistance benefits provided by
government or vocational rehabilitation (Vocational Rehabilitation
Services Act)
v. Required by a health facility under the Independent Health Facilities Act;
vi. Respecting the health status of a child who:
(a) Is in the supervision/care/custody/control of the Children's Aid
Society;
(b) Resides in a place of secure custody, a place of open custody or a
place of temporary detention, within the meaning of Part IV of the
Child and Family Services Act; or
(c) Resides in a children's residence licensed under Part IX of the Child
and Family Services Act.
Note: This exemption does not apply to medical services and the
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resulting reports generated at the request of the Children's Aid
Society to determine eligibility as a foster parent.
vii. Required as evidence of disability, or for the purposes of eligibility for a
benefit, related to transportation under any legislation or government
program.
viii. Required to obtain consents to perform insured services.
(k) A service provided by a laboratory, physician or hospital that supports one of the
above services (excluding the noted exemptions) is also an uninsured service.
Please note: Physicians are reminded that they may not bill for the following services that
are considered to be constituent elements of the insured medical services.
For a complete list of the common elements of insured services that
physicians cannot bill as uninsured services, please refer to the OHIP
Schedule of Benefits General Preamble pages GP – 3 through to GP - 6.
Nothing in the third-party regulation allows a physician to bill:
(a) For keeping or maintaining appropriate physician records.
(b) For conferring with, or providing advice, direction, information, or records to
physicians or other professionals concerned with the health of the insured person.
(c) For obtaining consents or delivering written consents.
(d) An annual administrative or any other fee associated with office overhead costs
(including but not limited to the cost of computerizing billings, storage of patient
medical records, time spent arranging appropriate follow-up medical care for insured
services etc.)
III. Calculating Fees for Third-Party and Other Uninsured Services
In calculating fees for uninsured services, including third party services but excepting the
services described in Section I: Definition of Uninsured Services under "At Physician's
Cost", the physician should take into consideration, as circumstances dictate, some or all of
the following factors:
A. Nature and complexity of the matter;
B. Experience and expertise of the physician;
C. Time spent with and/or on behalf of the patient;
D. The cost of materials not included in the fees for insured services.
Alternatively, physicians providing uninsured services, including third-party services, may
wish to refer to the OMA Schedule of Fees, which takes into consideration the above factors
for specific items, to determine fees to be charged. Another approach includes setting an
hourly rate (please refer to Item 9 below - page 14 of this Guide). In addition to physicians
charging an annual fee to patients for uninsured services, including third party services,
physicians may enter into annual financial contractual arrangements directly with third
parties for the provision of third party requested services and the completion of the
corresponding forms.
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The following tables provide examples of relevant medical services, common reports and the
associated OMA suggested fees. The fees are presented to help physicians determine
appropriate charges for third-party and other uninsured services.
Please note: All recommended rates for medical services are effective April 1, 2005.
Recommended rates for form fees are effective January 1, 2005. For
recommended rates for medical services prior to April 1, 2005, please consult
the 2004 edition of this Guide, the 2004 OMA Schedule of Fees or contact the
OMA’s Department of Economics.
1. Consultations and Visits
Please note: Consultation and visits are uninsured services (billable to the patient or third
party) when provided in connection with third-party services as described in
Section II of this Guide.
General and Family Practice Code OMA Fee
Consultation A005 $104.06
General Assessment A003 $102.96
Intermediate Assessment A007 $52.00
Minor Assessment A001 $32.93
Annual Health Examination - child after second birthday K017 $56.31
2. Other Relevant Uninsured Services
Service OMA Fee
Dispensing Service Fee (not to apply to provision of drug samples, only
where there is recorded purchase of drugs) $10.15
Electrocardiogram for insurance companies (technical component only, no
interpretation required) $13.43
Venipuncture (performed for insurance companies - sole purpose of visit) $21.02
Diagnostic interview and/or counselling with child/parent for testing per 1/2
hour (K003) $95.96
Maximal Stress Electrocardiogram for insurance companies (technical
component only, no interpretation required) $150.30
Certification of incompetence (financial) including assessment to determine
incompetence (K624) $195.76
TB Mantoux Test (A composite fee consisting of a minor assessment fee and
an injection fee. Patients would be responsible for the cost of the serum.) $37.20
3. Immunization as an Uninsured Service
There are some instances where immunization is not an insured service. Patients receiving
uninsured immunization may be charged for the service and the cost of the serum. Members
should note that the Ministry of Health and Long Term Care also advises that immunization
received solely for the purpose of travel outside Canada is an uninsured service. Only
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immunization for communicable diseases endemic to Canada is an insured service.
4. Recommended Fee Charges For Photocopying and/or Transfer Of Medical Records
The recommended minimum fee charges for photocopying and/or the transfer of medical
records for an individual is $31.45 for pages 1-5 and $1.23 per page thereafter when the
transfer of records occurs at the request of the patient because the care of the patient is being
transferred at the request of the patient or the patient's representative. Please note that these
suggested rates can be altered at the discretion of the acting physician.
In situations where the patient’s charts include services of a psychiatric nature the physician
must be extremely diligent when reviewing the type of information that is transferred; this
entails above average time on the part of the physician. The recommended fee for the
transfer of such records is $42.06 for pages 1-5 and $1.70 per page thereafter.
Note: The Ministry of Health and Long Term Care has also advised that physicians are
entitled to charge for the transfer of records when the transfer (performed at the
request of their patients) is due to the physician relocating or leaving the practice. In
these instances it is advisable that patients be contacted, either in writing or verbally,
and asked whether they wish to have their records transferred to a specific practice.
In instances where patients give approval of transfer to a specific location, there can
be a charge for the transfer of records. In instances where physicians, because of
their relocation or leaving practice, transfer all records to a new practice there should
be no charge to patients unless the latter contact the new practice and request that
copies of the records be transferred to a different physician of their choice.
The function of transferring medical records includes a variety of activities in addition to the
simple act of photocopying medical records. The following is an example of the activities
performed by the physician and/or the physician’s office staff when the transfer of medical
records is related to a transfer of care of the patient:
􀂾 The physician from which the patient is transferring receives the request and
makes sure that the proper authorization form is included and signed by the
patient(s).
􀂾 The physician reviews the chart, estimates the cost of the transfer. In some
instances and with the patient’s permission, the physician may decide which
parts of the records are necessary to be photocopied and transferred. While this
is time consuming it ultimately saves the patient from having to pay for the
transfer of many years worth of trivial and no longer relevant medical
information.
􀂾 The physician’s office staff communicates with the patient and explains that
there will be a charge for the transfer of records and quotes the estimated rate.
The physician asks the patient to sign and return a form acknowledging the
quoted charge and that they are financially responsible for settling the account
following the transfer.
The importance of appropriate communication with patients prior to the initiation
of the transfer must be stressed. Patients should be informed, in advance, that
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the transfer of medical records is an uninsured service (not covered by OHIP)
and, where possible, given an estimate of the cost of the transfer.
Members should be aware that patients quite often do not realize that the
originals of their charts are never transferred rather these remain in the
physician’s practice for a minimum of 10 years.
􀂾 Once the form is received from the patient, the chart is reviewed (if this hasn’t
previously occurred), or the relevant areas of the chart that have been selected by
the physician are photocopied.
It is important to note that staff may have to remove the chart from the premises
to get it copied, or in the event the office has access to a photocopier, the office
staff person will have to copy the relevant pages (while ensuring that the original
chart remains in order). It is important to also understand that photocopying a
chart during office practice hours is disruptive to office administration and even
more so when staff have to leave the premises.
􀂾 The original chart is returned to an area of the office records that contains the
inactive files and is stored for at least ten years after the date of the last entry in
the record, or until ten years after the day on which the patient reached or would
have reached the age of eighteen years (according to the CPSO requirements).
􀂾 The physician transfers the copy of the chart (either directly to the patient in a
sealed envelope) or by mail.
There are some instances where patients claim economic hardship and inability to comply
with the fees they are charged by doctors for the transfer of the records. It is important for
our members to realize that the OMA rates are recommended rates and that they (or their
office staff) should use their judgement in reducing the fees in instances of financial
hardship. In fact, the Canadian Medical Association’s Code of Ethics (April 1990) clearly
states under Article 24 that “an ethical physician will consider, in determining professional
fees, both the nature of the service provided and the ability of the patient to pay (emphasis
added), and will be prepared to discuss the fee with the patient.”
5. Uninsured Report Forms
Please note: For third party requested services, physicians can generally charge for the
completion of a report in addition to the appropriate assessment fee.
The following suggested fees were developed with the assistance of representatives of the
relevant OMA Sections and Forms Committee. This is only a sample of forms that exist in
the public domain. Where there is no recommended fee for a specific form a physician
encounters, the OMA suggests billing the third party for the time required to perform the
service; i.e., hourly rate (please refer to Item 9 below – page 14 of this Guide).
Uninsured Report Forms
Suggested
Fee
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Completion of Form Physicals for:
Schools
Camps
Pre-employment Certification of Fitness
Fitness Clubs
Hospital/Nursing Home Employees
$18.77
$18.77
$25.03
$25.03
$25.03
Completion of Licensing Forms/Certificates:
Drivers Medical Examination (FLRC80)
Pilots Civil Aviation; form 26-0010(0890)
Pilots License Validation 26-0055(01-91) - When completed with the Pilot’s Civil
Aviation form 26-0010(0890), the physician may consider not charging this fee.
Administrative License Suspension Appellant Medical Information Form
$37.56
$62.62
$12.52
$30.70
Completion of Work & School Related Forms/Notes:
Back to Work Notes
Sick Notes
Federal Employee Absence Notes; blue form
Day Care Note (free of communicable disease)
$12.52
$12.52
$18.77
$12.52
Insurance Certificates:
Treatment Plan, form #OCF-18 (formerly OCF 18/59)
Disability Certificate, form #OCF-3 (formerly OCF –3/59)
Certificate of Health Practitioner, form #OCF-8
Determination of Catastrophic Impairment #OCF-19/59
Approval of an Assessment or Examination #OCF-22
Travel Cancellation Insurance Form
Life Insurance Death Certificate
Medical Certificate for Employment Insurance Compassionate Care Benefits
$93.94
$93.94
$30.70
$77.07
$93.94
$25.03
$31.31
$30.83
Government Forms:
Citizenship and Immigration Canada Medical Report for Immigration
CPP Disability Medical Report Form (The federal government pays $65 for completion
of this form, physicians may bill patients for the remainder of the fee.)
Request for Medical Information Regarding Applicants to Canadian Armed Forces
Central Collection Service Request for Physician’s Information
Revenue Canada, Federal Disability Tax Credit
Auto Sales Tax Rebate Form
$93.94
$93.94
$73.71
$93.94
$31.31
$25.05
Other Certificates:
Childrens’ Aid Society (CAS) Application Form for Prospective Foster Parent
UIC Disability/Maternity Certificate INS2019
$37.56
$18.77
6. Unremunerated Report Forms
As per Section II Third-Party Services, there are a number of exemptions in charging a fee
for the completion of a third party report form. The following is a list of some of the more
common forms that a physician is not permitted to charge an individual for its completion:
􀂾 Handicapped Parking Sticker Application forms
􀂾 Transit forms for the Disabled
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􀂾 Permanent Resident Card Forms
􀂾 Canadian Passport Application
􀂾 Request for Birth Certificates
􀂾 Children’s Aid Society Forms (See page 5 of Section II, (j), vi of this guide for
additional details)
􀂾 Ministry of Health and Long-Term Care Forms (E.g., Limited Use, Section 8,
Northern Travel Grants, Assistive Devices, etc.)
7. Canada Pension Plan (CPP) Forms
There are two distinctly different types of CPP forms that the federal government pays for.
i. The Disability Medical Report Form, which commands a $65 fee
ii. The Narrative Medical Reports for which the federal government pays up to
$150.00. Narrative Medical Reports are not the same as the Disability Medical
Report Forms and are usually initiated by correspondence from staff of the
Income Securities Programs Branch of Human Resources Development Canada.
The narrative reports will require a medical history, the date of onset of each
medical condition, an examination of findings, various excerpts of consultation
reports (including identification of the consultants), diagnosis, copies of tests, a
prognosis and course of future action.
The federal government will reimburse physicians according to the following
scale for Narrative Reports:
Service Fee
Photocopied information from the patient’s chart and/or a short
statement/paragraph (completed in less than 15 minutes) $25.00
Short narrative typed reply involving chart review and medical report
preparation (up to one full page and 15-20 minutes time) $50.00
Full narrative typed report that is more complex to review and prepare
(at least two pages and 40-45 minutes time) $100.00
Detailed and complete typed report that involves a more extensive chart
review and medical report preparation (3 or more pages, 60 minutes
time) $150.00
Note: There is nothing that prevents physicians from seeking reimbursement above these
amounts and billing patients the balance of any amount over and above these fees.
Physicians are reminded that they may charge patients for the cost of medical
assessments associated with the preparation of the preceding documents required by
the federal government.
8. Life and Health Insurance Uninsured Report Fees
There are numerous life and health insurance forms as well as numerous versions of
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similarly titled categories of insurance forms belonging to different companies. In what
follows, a general description of the specific form and a recommended fee will be provided.
Where members' fees are expected to vary from the recommended fee, it is recommended
that members communicate this to the insurance companies requesting the form.
Attending Physician's Statement Fee: $93.90
Insurance companies request completion of this form after clients have applied for insurance
coverage and have provided the company with information on their medical history and
other biographic data. This form is usually sent directly to the physician, accompanied by
the patient's signed consent form, and is a request for historical medical information directly
from the patient's medical charts. The physician's findings, treatment and opinion recorded
following a patient's visits for significant medical problems are requested.
In these instances, insurance companies do not generally require a medical assessment to be
performed on the patient since this is not a request for information on the current health
status of the patient. The insurance company may request relevant copies of lab test results
and/or electrocardiograms.
Note: In the event the patient is making a disability claim, the insurance company may
require a medical assessment and up-to-date information on the health status of the
patient. As per Section II, item (f) of this guide, the assessment is insured and
billable to OHIP, if in the opinion of the physician the service is medically
necessary. Completion of the report remains uninsured and is billable to the patient
or third party. For additional information please consult the Ministry of Health and
Long Term Care’s Schedule of Benefits Appendix A, page 4A, point 1.2.1.
System or Disease Specific Questionnaire Fee: $62.62
This form is usually sent directly to the physician along with the patient's signed consent
form. The questionnaire will ask for specific details related to a patient's medical condition.
For example, in the case of a patient with diabetes, past blood sugar readings, treatment
given, control details etc. would be requested. Unless specifically requested, a medical
assessment is not required to complete this form since it is not a request for a report on the
patient's current medical status.
Insurance Medical Examination Fee: $153.40
This is a request by the insurance company for a general physical examination and the
completion of the accompanying form which usually includes questions making up a
functional inquiry, a past history of the patient's health status and the results of the physical
examination.
Systems Specific Examination Fee: $75.15
This is a request by the insurance company for an assessment that includes a single system
medical history and examination. This would include a review of the pertinent medical
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history relating to the system, a system specific examination and the completion of the
corresponding form.
Clarification Report Fee: $250.51/hr
This report is usually requested directly from the physician in order to adjudicate a claim. It
involves answering specific questions to clarify information about medical and
administrative details previously submitted to the insurance company. A medical
examination is not usually required unless specifically requested by the insurance company.
Full Narrative Report Fee: $250.51/hr
This report is usually requested by the insurance company in order for the physician to
answer detailed questions to clarify information about medical and administrative details.
This is quite common in cases of prolonged or complex disability (e.g., chronic fatigue
syndrome) or psychiatric illness. It is usually requested in a letter type format and insurance
companies usually require that copies of appropriate test results and consultation reports also
be included with the response. A medical examination is not usually required unless
specifically requested by the insurance company.
Independent Medical Examination Fee: Independent Consideration
Usually contracted between a physician and insurance company; fees are usually discussed
in advance with the physician based on the insurance company's requirements.
9. Establishing An Hourly Rate
There are several approaches that can be used when setting your fees for uninsured services.
Approach #1
One approach to setting your fees for uninsured services, including third-party services, is
according to the time required to provide a particular service. This can be achieved by
establishing an hourly rate based on your annual gross earnings.
Important Note: Any hourly rate calculated using a physician's earnings is primarily
based on earnings derived from the provision of insured services
(gross OHIP billings). At the time of publication of this Guide, OMA
recommended rates were approximately 81% higher than OHIP
rates. As such, the hourly rate calculated should reflect the
uninsured nature of the particular services provided. Further, the
particular expertise of the physician providing the uninsured
report/service should be taken into consideration.
The following example illustrates one way to determine an hourly rate:
Row Item Calculation
Page 15 of 28
A
Annual gross OHIP billings:
(Please note that when using OHIP income this should be
income before thresholds are applied)
$200,000
B Converted gross OHIP billings:
($200,000 x 1.81) $362,000
C Other annual income:
(E.g., third party billings at OMA recommended rates) $20,000
D
[B + C]
Total annual gross earnings:
($362,000 + $20,000) $382,000
E Working days per year:
(52 weeks x 5 days/week less 30 days vacation & holidays) 230 working days
F
Income generating hours:
(9 hours in practice less 2 hours of (paid clinical time) unpaid
non-clinical activity per working day
7 paid hours/day
G
[=E x F]
Annual paid hours:
(230 days x 7 hours/day) 1,610 paid hours
H
[=D x G]
Hourly rate:
($382,000/1,610 hours) $237.27/hour
Approach #2
In establishing an hourly rate, physicians may also be guided by the part-time hourly rate
shown in the Scale of Grading and Remuneration listed in the OMA Schedule of Fees. The
recommended part-time hourly rate for the 2005 calendar year is $210.00 plus associated
expenses.
Physicians with regular office practices can use a sessional gross hourly rate to account for
office overhead costs they incur while working on a sessional basis. This would require
adjusting the net hourly rate of $210.00 upward to account for the individual physician's
overhead costs.
10. Block and Annual Fees
In June 1995 the Ontario Divisional Court struck down the ban in s. (1) paragraph 23 of
Regulation 856/93 under the Medicine Act, 1991 on the charging of annual fees by
physicians. As a result, it is not unlawful for physicians to charge their patients an annual or
block fee that covers the delivery of uninsured services.
The College of Physicians and Surgeons of Ontario (CPSO) recommends that, when offering
their patients the block fee option, physicians should inform them in the following manner:
“Most of your medical needs are covered by the Ontario Health Insurance Plan
(OHIP). But there are some services that are not covered. You can be charged for
Page 16 of 28
these services one by one, or you can be charged a block fee which would cover all
the services which are not paid by OHIP for periods of time not less than three
months or more than 12 months. The College of Physicians and Surgeons of Ontario
has set out rules, which doctors must follow if they wish to charge block fees. These
are:”
1. An annual/block fee must be identified as a fee for uninsured services for a
period of not less than three months and not more than one year.
2. The services covered by this fee must be clearly stated, in writing, and
understood by the patient.
3. The patient must be advised of the amount of the individual charges.
4. The patient must be given the option of paying individual charges for the
uninsured services as they are rendered.
5. The decision as to whether or not to elect this form of payment must be the
patient’s, and must not be a condition of the patient being accepted by the doctor.
6. The patient must be given a copy of this policy statement and indicate their
acceptance of paying for uninsured services in this manner before being billed an
annual fee.
7. Fees for the service of being available to render a service cannot be charged in
advance and are not to be included in annual fees.
Please refer to Appendix I (see page 28) for an example of a sample letter on annual fees that
may be sent to patients, which appeared in the April 1996 edition of the Ontario Medical
Review, pp. 27-29.
Physicians may also enter into an annual fee arrangement with third parties for the provision
of third party requested services.
11. Reports Requested by Employers and Other Issues Related to Workers’ Compensation
There are instances where employers ask that workers injured in the workplace get their
physicians to complete employer-specific forms related to early return to work or modified
return to work. Completion of such forms and any related assessments and/or tests is an
uninsured service and should be charged to the patient or, where possible, the employer.
These forms are not to be confused with the corresponding Workplace Safety and Insurance
Board (WSIB) forms which command a fee payable by the WSIB. For a list of the WSIB
report forms and their associated fees contact WSIB at 1-800-569-7919 or visit their website
at www.wsib.on.ca.
There are also occasions where patients ask physicians not to report work-related injuries to
the WSIB but to bill these to OHIP instead. Physicians are reminded that billing WSIB
covered medical services to OHIP is fraudulent and results in significant cost-shifting to
the OHIP pool. On the other hand, reporting an injury to the WSIB against the patient’s
desire could be construed as an act of professional misconduct by breaching the
confidentiality provision of the Medicine Act.
Page 17 of 28
In instances where the patient insists that the injury not be reported to the WSIB, it is
recommended that physician bill the patient directly for the cost of the medical services.
Further, it is recommended that physicians ask that the patient sign a form acknowledging
that they release the physician of any future liability for future health complications related
to the particular injury.
IV. The Application of GST to Uninsured Services - Some Guidelines
1. Advance GST Rulings versus GST Application Rulings
Canada Customs and Revenue Agency offers two types of rulings concerning the application
of GST: “advance GST rulings” and “GST application rulings”. Both are provided free of
charge.
An Advance GST Ruling is a written statement provided by Canada Customs and Revenue
Agency to a registrant or other person, stating how Canada Customs and Revenue Agency
will interpret specific provisions of Part IX of the Excise Tax Act with respect to supplies,
actions, transactions, or series of transactions, which the person is contemplating. This
ruling refers to specific persons, specific transactions and specific time periods within which
the transaction must be completed. Consequently, a request that relates to a hypothetical
situation cannot be viewed as a request for an advance GST ruling. Physicians often have
questions regarding the application of GST in a particular instance. If they are asking for an
interpretation that specifically relates to a proposed activity or set of activities, then they
should request an Advance GST Ruling and all necessary facts should be provided.
A GST Application Ruling provides Canada Customs and Revenue Agency’s position on
specific provisions of the legislation as they relate to a clearly defined factual situation of a
particular person. Generally, GST application rulings relate to ongoing transactions and do
not specify time limits.
Physicians should also note that they are required to register, collect and remit GST when
their annual GST-taxable sales and revenues exceed $30,000. For those physicians not
exceeding this amount, GST registration is voluntary. Physicians should note that the
following information on which uninsured services attract the application of GST does not
constitute official advance GST rulings and is provided for information purposes.
2. GST and Block/Annual Fees
Block or Annual fees (described in Section III (j) of this Guide) are considered taxable
supplies since, at the time they are billed and paid for by the patient, there are no specific
services being provided. These fees are similar to an insurance premium and ensure the right
to a future service(s), the exact nature of which is (are) not predetermined.
3. GST and Medical Legal Reports
Medical legal reports are statements of fact and/or opinions regarding the physical/mental
condition of a patient pertaining to an occurrence (e.g. automobile accident). Such reports
are considered to be taxable supplies and attract GST, even in if there has been an
examination of the patient required to complete a medical legal form.
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The only exception is in instances where the medical examination is an insured service for
which a claim is submitted (and paid for by) the Ministry of Health and Long-Term Care. In
such a case, the medical service is tax exempt (pursuant to Section 9 of Part II of Schedule V
of the Excise Tax Act) and is considered a separate supply from the medical legal report.
4. GST and Independent Medical Evaluations (IME)
IME’s are medical evaluations conducted, on the request of a third-party, such as an
insurance company or a lawyer, by a physician who did not have a previous relationship with
the individual. IMEs are contracted between the physician and a third-party, with fees being
agreed upon in advance.
A 2002 Federal Court of Appeal decision held that IMEs provided are supplies that are GST
exempt. Canada Customs and Revenue Agency (CCRA) has written an “interpretation” letter
which states that it will not apply this decision to all persons who perform IMEs, but only to
those who fall within the identical fact situation as the decided case. CCRA lists six criteria,
which in its view have to be met by the IME supplier for the IME to be GST exempt.
Therefore, CCRA will continue to require that all persons who perform IMEs and like
reports should continue to charge GST unless they receive advice from their lawyers or
accountants that they fall within the criteria stated by CCRA. Members should note that
CCRA interpretation letters are not legally binding upon CCRA or the courts.
5. GST and Insurance Forms
System or disease-specific questionnaires
This is an insurance form that is usually sent to a physician (along with a signed consent
form) asking for specific details related to a patient’s medical condition. According to
Canada Customs and Revenue Agency, this report prepared by the physician for the purpose
of determining eligibility for insurance coverage is exempt from the GST.
Clarification Report
Generally a medical examination is not required when an insurance company requests such a
report. According to Canada Customs and Revenue Agency, such reports are subject to the
GST.
Treatment Plan (Form OCF-18/59)
This type of report is completed to determine the present health status of an individual, and
to either rule out, confirm or recommend a necessary treatment modality. Since physicians
will involve themselves in consultative, diagnostic or other health care services in order to
assess the patient’s health status and recommend appropriate treatment plans, this report is
exempt from the application of the GST (pursuant to Section 5 of Part II of Schedule V to the
Excise Tax Act).
Disability Certificate (Form OCF-3 – formerly OCF3/59)
Page 19 of 28
In completing this form (which is requested by the insurance company in the event of
disability claims or legal action) physicians are not required to examine patients since this
has already occurred in the context of previously assessing and treating the patient. In cases
where there is a medical examination performed, it is solely for the purpose of confirming
physical/mental pathology as a result of the previous incident. Consequently, such
certificates are subject to the GST.
CPP Disability Reports/Disability Tax Reports
For the same reason as the previous certificate, such reports are subject to the GST.
6. GST and Other Uninsured Services
The following uninsured services are considered by Canada Customs and Revenue Agency
to attract application of the GST:
i. Review of documentation and provision of expert opinion by physicians
ii. Management fees paid by physicians for administrative services, use of facilities,
equipment, etc.
iii. Surgical services and all related medical services that are provided for cosmetic
purposes
Canada Customs and Revenue Agency consider the following uninsured services GST
exempt:
i. Employer generated return to work/modified employment/timely return to works
forms
ii. Preparation and transfer of medical records at the request of the patient or his/her
representative
iii. Provision of a prescription to an insured patient at the request of the patient (or
his/her representative) and no concomitant insured service is provided
iv. Executive medical assessments
v. Employment and pre-employment examinations/reports
vi. Immigration examinations/reports
For more information regarding the GST you can call Canada Customs & Revenue toll-free
at 1-800-959-8287 or refer to their website at: www.ccra.gc.ca.
V. The Preparation of Medical Legal Reports
Medical legal reports are essential to the legal process of adjudicating claims for personal
injury. A well prepared medical legal report will contribute significantly to the proper and
just resolution of a claim for personal injury, expedite the process, reduce cost and frequently
obviate the necessity of a court appearance by the physician.
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1. Confidentiality
Given that the relationship between a patient and a physician is one of highest
confidentiality, a physician should insist on being provided with a valid and adequate written
consent to the release of medical information. While the very request for medical
information by a lawyer or firm professing to be retained by the patient may be considered as
an adequate consent of the patient, it is recommended that the lawyer requesting the
information provide the physician not only a clear statement as to the lawyer's representation
of the patient but also a valid and adequate consent of the patient. It is the lawyer's
responsibility to provide the physician with such consent.
2. Code of Ethics
The responsibilities of an ethical physician to the patient is stated in the Code of Ethics
issued by the Canadian Medical Association in April 1990 include the following:
"An ethical physician, will, upon a patient's request, supply the information that is
required to enable the patient to receive any benefits to which the patient may be
entitled." (Section 9)
This is reinforced by Section 1.17 of Ontario Regulation 856/93 made under the Medicine
Act, 1991 which defines professional misconduct to include:
"Failing without reasonable cause to provide a report or certificate relating to an
examination or treatment performed by the member to the patient or his or her
authorized representative within a reasonable time after the patient or his or her
authorized representative has requested such a report or certificate."
VI. Physicians as Expert Witnesses
1. Non-Treating (Retained) Physicians
Non-Treating physicians are often approached by lawyers or the Crown to testify as an
expert witness and usually have never seen the patient prior to being contacted. After
agreeing to act in such a capacity, physicians may examine the patient so as to establish an
expert opinion regarding matters such as the patient's injuries or standards of previously
provided medical care.
The fees payable to an expert witness are a matter for negotiation between the expert witness
and the lawyer seeking the expertise. In addition to a compensation arrangement for time
spent in the courtroom, physicians should not neglect to agree on a fee, in advance, for
reports that may be produced as well as travel time and other expenses incurred in the
process of acting as expert witnesses. Whenever possible, it is recommended that
physicians seek agreement on their fees, in writing.
A non- treating physician is under no obligation to agree to act as an expert witness. The
expert witness will rarely receive a subpoena or summons to attend in court since he/she has
Page 21 of 28
agreed to act as an expert in advance and has secured satisfactory remuneration for this
expertise.
When testifying in court, the expert witness is usually given a set of facts, which closely
resemble the actual case and is then asked hypothetical questions based on those facts. The
expert witness will provide a professional opinion based on the examination of the patient,
the medical records and knowledge of similar previous cases.
i. Fees for Civil Lawsuits or Administrative Bodies
In these lawsuits, an expert's fees are a matter of negotiation between the expert and the
Crown attorney or defense lawyer. The only limit is that these fees not be excessive in
relation to the services provided by the expert witness.
ii. Fees for Expert Witnesses in Criminal Cases
In these lawsuits, expert witness fees are a matter of agreement between the expert witness
and the Crown attorney or defense lawyer.
The Ministry of the Attorney General generally pays experts in accordance with a schedule
of fees. However, there is nothing that prevents expert witnesses from seeking
reimbursement above these amounts.
The OMA has suggested the CMPA rates for both general practitioners and specialists of
$250 per hour or $2,000 per whole day. Arrangements should, however, be made prior to
agreeing to act as an expert witness. The Ministry of the Attorney General fee schedule does
not apply to those expert witnesses retained by the defence.
The Ministry of the Attorney General schedule of fees is as follows:
A. Travel Time $45/hr
B. Preparation, Interviews, Consultations
- GPs and family physicians $90/hr
- other specialists $100/hr
C. Witness Fee - Hourly Rate
- GPs and family physicians $110/hr
- other specialists $125/hr
D. Witness Fee - Half Day Rate
- GPs and family physicians $300
- other specialists $325
E. Witness Fee - Whole Day Rate
- GPs and family physicians $600
- other specialists $650
Page 22 of 28
2. Treating Physicians
Treating physicians will typically be served with a subpoena or a Summons to Witness to
appear in court or before an administrative body and would be subject to arrest, detention,
and ordered to pay costs that have arisen for failing to attend if properly served. A physician
may only be excused from responding to a Summons if ordered so by the presiding Judge.
The court will only excuse or adjourn the attendance date of a witness for drastic reasons,
such as serious illness of the physician, a death in the immediate family, or absence from the
country. The physician must have a representative attend in court to explain the absence and
the particular circumstances or have received prior approval not to attend from the party that
subpoenaed the physician. Previously scheduled surgical obligations or appointments will
generally not be viewed by a court as a reason to excuse a physician.
The party who Summons the treating physician to testify in court is only obliged to pay the
physician the daily attendance fee in accordance to the rules that regulate the procedures of
that particular trial or hearing, such as the Rules of Civil Procedure, The Family Law Rules,
and the Interim Rules of Practice and Procedure of the Financial Services Commission of
Ontario. Tariff A of the Rules of Civil Procedure state that the daily attendance allowance
for a witness is $50. The Tariff also lists the appropriate travel allowance, and the
appropriate overnight accommodation and meal allowance, if applicable. Please note that the
amounts listed in the Tariff may vary from year to year.
Treating physicians will often be called or Summonsed as witnesses where they were the
first party to see or treat the patient. An example would be a case where a physician saw and
treated a patient in the emergency room or was the patient's family doctor and was treating a
particular injury or condition. The witness in these cases would generally be asked the facts
about the treatment and/or prognosis regarding the patient's health.
There is no question that occasionally the boundary between a treating physician and a
retained expert witness becomes blurred. In instances where a physician has provided
ongoing care for a patient, a lawyer may request further examination and diagnostic testing
as well as an extensive report and an opinion concerning the patient's recovery, in addition to
testimony in court. Some of these services could be considered to be those of a retained
expert witness.
In such cases, the physician should request compensation as an expert witness. The lawyer
requesting such services may argue that these are matters inextricably linked to the witness
role as the treating physician and refuse to pay. In these cases, the physician who has been
previously served with a Summons or subpoena is still legally obligated to attend court and
provide all the relevant documentation and testimony. The physician should consult in
advance with the particular lawyer requesting attendance in court in order to arrive at a
mutually agreeable attendance fee. However, it must be pointed out that, in this case, it is
conceivable that the physician may only receive the minimum payment (as stated above) for
attendance in court. The physician would be entitled to payment for the production of any
medico-legal reports prepared in the matter.
VII. The Direct Billing Process
Page 23 of 28
1. Some Practical Guidelines
There are some practical guidelines physicians can follow when billing a patient directly to
help make the process as comfortable and efficient as possible.
When calculating fees, physicians should consider the financial burden such charges might
place on the patient, and be prepared to reduce or waive fees based on these considerations.
When billing directly for services provided, physicians should:
i. Establish and maintain a simple and clear office policy and procedure for direct
billing;
ii. Inform staff of this policy and procedure and keep them apprised of any changes;
iii. Maintain up-to-date accounts;
iv. Collect payment from patients at the point of service as often as possible;
v. Follow-up in an orderly and consistent manner;
vi. Always discuss fees with the patient before providing the service.
To establish a consistent office policy, physicians should first determine:
i. Those services for which patients will be directly billed;
ii. The fees attached to those services;
iii. Any exemptions, such as seniors or those on fixed-incomes;
iv. Bookkeeping and collection procedures.
A physician's office policy on direct billing must be specific and detailed so that staff and
patients fully and clearly understand it. At the same time, it should allow sufficient
flexibility to adapt to any unique or unexpected circumstances that may be encountered.
Once an office policy has been established, it should be put in writing and distributed to
staff.
2. Keeping Patients Well-Informed
Most difficulties between a physician and patient arise from a lack of clear communication.
Many patients simply don't realize that there are some services government doesn't pay for,
and they may become upset when presented with a bill. To prevent this from happening,
physicians and their staff must ensure that patients are well informed about uninsured
services and the direct billing policy well in advance of receiving treatment.
The following are a few suggestions on informing patients about direct billing:
i. Clearly display in your patient waiting area a poster (refer to Appendix II, pg 27)
and an itemized list of those third-party services you offer.
ii. Discuss fees when the patient books an appointment for an uninsured service.
iii. Mention fees before you provide the uninsured service.
iv. Provide an information pamphlet to the patient that includes:
Page 24 of 28
􀂾 General information (e.g., office hours, telephone hours, after-hours
procedures, prescription refill instructions)
􀂾 Direct billing information (e.g., services that are directly billed by you and
not insured by government, procedures for third-party claim forms).
Keep in mind that this pamphlet need not be a complicated and costly publication. However,
it should reflect your professionalism, and information should be presented in a clear and
concise fashion.
3. Charging Interest on Unpaid Accounts - Some Guidelines
Quite often physicians encounter instances whereby accounts relating to third party
uninsured services remain unpaid in spite of recovery efforts or are paid on a delayed basis.
Physicians are reminded that they are entitled to charge interest on unpaid/delayed accounts.
There are, however, certain guidelines that physicians should keep in mind when exercising
this option:
i. If an invoice to pay is directed to the patient without explicit mention of interest
payable on late payment then, in accordance with section 128 of the Courts of
Justice Act (Ontario), physicians may not charge a rate exceeding the Bank of
Canada rate (rounded to the nearest tenth).
ii. If an invoice to pay claims interest for late payment, the courts have determined
(section 4 of the Interest Act of Canada) that “no interest exceeding the rate of
5% per annum shall be chargeable, payable or recoverable on any part of the
principal money unless the contract contains an express statement of yearly
rate” (emphasis added). In other words, a statement of only a monthly rate of
interest is not sufficient if members wish to charge an annual rate exceeding 5%.
iii. Physicians that include mention of late payment interest charges in their
submitted invoices (specifically mentioning the annual rate) may charge up to an
annual effective interest rate of 60%. Anyone entering into an agreement or
receiving payment of a greater interest could be found guilty of a criminal
offence under section 347(1) of the Criminal Code.
VIII. Collecting Unpaid Charges - The Small Claims Court System
In the event physicians are unable to collect the fees charged for uninsured services they
might wish to resort to the Small Claims Court system. When considering this option
physicians are reminded that:
i. In order to initiate a Small Claims Court claim one must obtain a statutory form
from the local court.
ii. One must hire their own process server or bailiff to serve the claim.
iii. The court now requires you to pay $100 to set the action down for trial either as a
defended or undefended matter. This is similar to what happens in the Superior
Court of Justice, formerly known as the Ontario Court (General Division).
iv. The limit for a small claims court judgement is $10,000.00 plus pre-judgement
interest and (costs in excess of the limit must be foregone in order to receive a
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small claims court judgement).
v. Once the Claim has been issued, the debtor has 20 days within which to file a
Defence, measured from the date of service. Assuming a Defence is filed then
the court office will notify the physician of the trial date.
vi. The appropriate (geographically) Small Claims Court must be selected for the
issuance of the claim. Each court has a limited geographical jurisdiction. With
the exception of the City of Toronto (which is divided into two districts - the
Toronto Small Claims Court and the North York Small Claims Court) selection
of the appropriate court is straightforward. Physicians should contact any small
claims court office if they are unsure of the correct jurisdiction.
IX. Useful Websites
Ontario Medical Association www.oma.org
College of Physicians & Surgeons www.cpso.on.ca
Workplace Safety & Insurance Board www.wsib.on.ca
Ministry of Health & Long Term Care www.gov.on.ca
Canadian Medical Association www.cma.ca
Canada Customs & Revenue www.ccra.gc.ca
Auto Insurance Accident Claim Forms www.fsco.gov.on.ca
Federal Forms www.canada.gc.ca/form/eservices_ehtml
Family Practice Section www.familydoctorsofontario.com
X. Useful Telephone Numbers
Ontario Medical Association 416-599-2580, toll free 1-800-268-7215
Canadian Medical Association 1-613-725-2000, toll free 1-800-267-6522
College of Physicians & Surgeons 416-967-2600, toll free 1-800-268-7096
Ontario College of Family Physicians 416-867-9646
Ontario Hospital Association 416-205-1300
MOHLTC Branches:
- Provider Services 1-613-548-6561
- Drug Programs 416-327-8109
- Public Health 416-327-4300
If you have any suggestions for the next edition of this Guide,
please forward these in writing to:
Page 26 of 28
Department o f Economics
Ontario Medical Association
525 University Avenue, Suite 300
Toronto, Ontario M5G 2K7
Email: economics@oma.org
Page 27 of 28
Appendix I: Sample Letter
New Information on Insured Services
At the ____ Clinic, your family physician has been delivering the best care possible
under increasingly difficult financial restraints imposed by a series of powerful
governments. The current federal and provincial policies toward health-care delivery
seem to be even more severe.
As a result, your family doctor will now be billing for all uninsured services, which the
Ontario Health Insurance Plan refuses to cover. In addition, there are third-party requests
for services for which you will now be required to pay: for example, back-to-work notes.
As always, your physician will keep in mind the financial impact of these charges in
individual cases.
Attached to this letter is the current list of uninsured services and third party services.
When making an appointment, please make it very clear if you require such a service
since the payment for such a service and the report may be your responsibility.
An important change for you this year is the choice of purchasing the Family Fee or
Individual Fee option which covers specific, designated uninsured services for one year.
You may prefer to pay for each individual service. This is purely voluntary and will not
in any way influence your care. If you choose the annual fee, please fill out the attached
form and pay at the time you wish to enroll. This plan may be renewed on an annual
basis. Should you choose to pay on a per-service basis, please be prepared at the time the
service is rendered. Ask your doctor or his/her staff should you have any questions.
Your understanding and co-operation is appreciated.
Page 28 of 28
Appendix II: Poster
Message to Patients
Did you know that OHIP does not pay for all of the services your doctor provides to
you? Physicians can request payment from patients for the services that are not covered
by OHIP.
Listed below are some examples of physician services that you can be charged for, by your
doctor:
NON-MEDICAL SERVICES
(some exceptions may apply)
∗ Transferred copies or a summary
of your medical records, at your
request, when changing doctors or
when your doctor is relocating or
leaving the practice
∗ Writing reports and filling out
forms. Examples of such forms are:
∗ Licensing / insurance forms
∗ Federal Government (Canada
Pension Plan, immigration, etc.)
forms
∗ Sick or back-to-work notes
∗ Medical legal reports
∗ Employer-requested reports
∗ Recreational camp forms
∗ Missed appointments without
sufficient notice
∗ Long distance telephone and
facsimile toll charges
SOME MEDICAL SERVICES THAT
ARE NOT COVERED BY OHIP:
(some exceptions may apply)
∗ Cosmetic procedures (including
some related consultations and
diagnostic tests)
∗ Acupuncture
∗ Pre-departure Travel Medicine
Services for the purpose of traveling
outside of Canada
∗ Routine eye examinations for
patients who request more than the
regulated amount covered by OHIP
∗ Examinations / diagnostic tests
required for the completion of
documents such as reports, forms
and licenses
∗ Medical advice over the telephone
or call-in prescription renewal orders
to the pharmacist
Block Fees may be offered, as an option, in place of some of the above non-OHIP covered
services.
Quality health care, medical advice and timely access are priorities Ontario’s physicians intend to
honour. Speak to your doctor about other health care services that are not insured by OHIP and
of the fees you may be charged.