An Introduction to OHIP billing

Most residents get some exposure to billing. During my residency, I was mostly exposed to family medicine clinic billing. A007 billing code was used to bill for most things, A001 for a simple prescription renewal, A003 for a periodic health exam... it was pretty simple.

The simplicity quickly disappeared once I started working in areas other than family medicine clinics. Nobody ever taught me how to go about emergency room billing or hospitalist work billing. I tried to find some resources, but couldn't seem to find anything helpful. I ended up learning by trial and error, some of which was quite painful. I hope that this series, an OHIP billing guide, will shed some light and give direction to those who must deal with the wonderful world of OHIP billing.

Billing Methods

The newly minted doctor needs a few things to get paid. You need an accountant. You need a financial advisor. You need an OHIP billing number, CPSO number, WSIB number; the list goes on and on...  Finally the doctor must decide how they want to go about their billing. There are two options: do-it-yourself (DIY) or hire a billing agent; both of which I will attempt to explain.

DIY option

The DIY option, which I have done in the past, is a difficult route given the little guidance I had available, but you learn a lot from the process. First, you need to get an EDT login and password. Second, you need a software where you can type in the patient info (name, DOB, OHIP #) as well as the diagnosis/billing codes. The software is used to churn out some text file that the government processing computer can understand.

Then comes the fun, archaic and techy part. You login to the EDT server via a modem (yes, a modem, like the old 90s dial up modems- remember those?) That means you need a computer with a modem which is a rarity these days, or you can buy a USB/PCI modem and plug that into your computer. Great, now you've logged into the EDT server with DOS user interface, which you haven't seen since probably high school. You navigate through the menus and upload the text file your software just made. The government looks at the file and will either filter out any obvious errors (like a DOB or OHIP # mismatch) or let the claim through. Ah, but you're not done yet. The government might still reject your claim if you used the wrong billing code or if you break one of the rules the government has set (for example, you cannot bill C007, a subsequent visit on weeks 6-13 for hospitalist work, more than three times a week). You will be notified about your claim rejections via the "Remittance Advice", a sort of summarizing report they give you every month. Hopefully most of your claims go through and you still get a cheque, but you also have to work through your rejections. Now the rejections get submitted on paper, yes paper, hand written and faxed or mailed.

Doesn't it sound complicated? It is, especially learning and doing it right the first time. Does it take a long time to learn the process? Yes it does. Do you like tedious data entry? Probably not. This is why most people choose to go with a billing agent who will do this work for you and make sure the rejections/errors are taken care of. Most of the time the expense is worth it. When I do hospitalist work, I could recuperate the billing agent fee, usually by avoiding one patient claim that doesn't go through for whatever reason. (Often times, the problem is not processing the rejections/errors within the time limit. OHIP gives 6 months from the date of service.)

Billing agent option
 
Once you find a good reliable billing agent you have to keep a record of all your billable services. In terms of patient data, you basically need the patient's name, DOB and OHIP #. For your service, you need the date (on which you gave the service), diagnosis code and billing code. You write all this down on a piece of paper (many people use 3x5 index cards on which they may stamp the patient's hospital card for instance.) Or if you have a receptionist at the clinic, often times they will prepare a list of patients with their data with a blank line for you to write the diagnosis and billing code. When you have a billing agent, you arrange a time and place to meet the billing agent. You pass off your records and the billing agent does the processing work, as well as deals with rejections/errors for you. Just as in the DIY option, you get a cheque from OHIP in your mailbox the next month. The billing agent takes a cut from this payment, usually about 4% (range I have seen is 2.5% - 5%).

Some common scenarios

For new graduates, this whole billing agent thing is some kind of black magic. Some clinics will offer to do the billing for you but you could also do it yourself. What happens if you work at two clinics? Three clinics? Or God-forbid you become a career locum tenens, working in a different clinic every month, week or even every day? Who looks at the monthly Remittance Advice to reconcile claim rejections from all the places you work at? Without a billing agent of your choice, one of the clinics, responsible for your billing, will be receiving and dealing with your monthly Remittance Advice and unless you work there often they might not put a lot of effort into making sure you get paid for the work done elsewhere.

In terms of hospitalist billing, it is mostly left to the doctor. The doctor is responsible for collecting and keeping daily patient records. This is one area of work where the doctor would benefit from a billing agent the most. ERs usually work as a group practice and have one billing agent working for the entire group.

That was somewhat of an oversimplified review of how billing gets done for most people. On the next installment we will try to get into the details of some billing situations.