Introduction
For healthcare professionals beginning their journey in Ontario, understanding how the Ontario Health Insurance Plan (OHIP) billing system works is crucial. OHIP is Ontario’s publicly funded healthcare plan, and it reimburses doctors and healthcare providers for services delivered to eligible residents. While it sounds simple on the surface, the system has layers of codes, rules, and documentation requirements that every provider must understand.
This blog post breaks down the basics of OHIP billing to help you start on the right foot.
What Is OHIP?
OHIP (Ontario Health Insurance Plan) is administered by the Ministry of Health and Long-Term Care (MOHLTC). It covers medically necessary physician and hospital services for Ontario residents. Healthcare providers must be registered with OHIP to submit claims and get paid for their services.
Who Can Bill OHIP?
To bill OHIP, you must:
- Be a licensed healthcare provider in Ontario (e.g., physician, optometrist, chiropractor).
- Be enrolled in OHIP with a unique billing number.
- Deliver services to OHIP-eligible patients.
Key Concepts in OHIP Billing
1. Fee-for-Service (FFS) Billing
Most physicians are paid on a fee-for-service model. This means they bill OHIP for each service using predefined fee codes from the OHIP Schedule of Benefits (SOB).
2. Schedule of Benefits (SOB)
The SOB is the billing Bible. Each service has a code, description, rules for use, and payment amount. For example:
- A007A: Intermediate assessment by family physician – $36.85
- K005A: Counseling (20 minutes or more) – $78.20
Always ensure you are using the most updated SOB version.
3. Group Billing
In clinics or hospitals, group billing may apply. This involves billing under a group number while still identifying the individual provider.
4. Shadow Billing
Used in Alternative Payment Plans (APPs) where physicians are on a salary but still submit claims to track service volume.
Getting Set Up for OHIP Billing
- Get a Billing Number
Apply to MOHLTC via the Application for Registration process. - Choose Billing Software or Agent
You can use billing software like MDBilling.ca, Dr. Bill, or have a third-party billing agent manage claims. - Understand Remittance Advice (RA) Reports
These are your payment reports. They show approved, rejected, or adjusted claims.
Common Billing Errors to Avoid
- Incorrect diagnostic codes: Ensure your diagnosis aligns with the service billed.
- Missing time or duration: Some codes (like counseling) require 20+ minutes.
- Double billing: Billing two overlapping codes for the same visit may result in rejections.
- Billing for ineligible patients: Always confirm OHIP coverage before service.
Claim Submission & Deadlines
- Submission timeline: Submit claims within 6 months of the service date.
- RA schedule: Payments are issued monthly, typically around the 15th.
- Re-submissions: Rejected claims can be corrected and resubmitted within the deadline.
Using Diagnostic Codes
OHIP uses ICD-9 codes for diagnoses. Always ensure they:
- Match the patient’s condition
- Are medically necessary
- Justify the billed procedure
Tracking and Reporting
Many providers use EMRs (Electronic Medical Records) integrated with billing software to:
- Track appointments and procedures
- Submit claims automatically
- Review rejections or underpayments
Conclusion
OHIP billing is both an art and a science. Mastering it ensures you get paid accurately and quickly. In our next blog post, we’ll explore intermediate and advanced billing techniques, including common specialty-specific codes, maximizing revenue, and managing rejections.
Stay tuned!
