Uninsured Services Medical Billing

Sometimes there can be confusion on what an uninsured service is, therefore the goal of this blog entry is to clarify the definition of uninsured services and to provide input on how to deal with uninsured services.

Any service which is not paid for by OHIP is considered an uninsured service. This includes any services which are not paid for by WSIB (see my previous blog entry).  These uninsured services are expected to be paid for by the patient. While there are several examples of uninsured services, the most common uninsured services doctor’s are faced with are requests initiated by third parties. Third parties exist in the form of insurance companies, law firms, employers; essentially any person/organization other than the patient. These third parties often request the completion of forms or reports pertaining to their client (your patient), which are categorized as uninsured services.

At times the definition of uninsured services may not be adequate enough in determining how to deal with a certain situation. For example, if the physician must examine the patient in order to complete a form requested by a third party, the examination in addition to filling out the form is an uninsured service and OHIP should not be billed for either. However, if the physician so happens to come across a medical problem during the examination which deems the examination to be a medical necessity, they can bill OHIP for the examination but not for the completion of the form. There always exist exceptions to rules. You can easily determine whether or not to bill OHIP for the service by asking yourself : “was the service medically necessary?”, if your answer is yes then bill OHIP for the service but continue to bill the patient (or third party) for completion of the form.  Another good example is the transfer of medical records- if a patient requests to have their records transferred to another physician and it is not medically necessary, the patient should be charged.

Setting up a fee schedule:

Third party requests are seemingly increasing; everyone seems to want patient reports. Schools for trips, employers for pre-employment assessments, license organizations for issuing licenses, etc. With uninsured services coming up so often, it is essential that an appropriate fee schedule for uninsured services be established. The OMA provides suggested rates for uninsured services and recommends that if you deviate away from their suggestions to be sure you are able to validate the rates chosen for uninsured services, as excessive prices can be considered professional misconduct.  TIP: Seriously check out the OMA suggested rates for uninsured services because you will probably notice some services you have been providing which you should be charging for.

Alternative to on the spot uninsured service charges:

A physician can setup Block Fees with their patients which encompasses a flat fee charged to the patient for a number of predetermined uninsured services during a predetermined amount of time. The amount of time must fall within 3-12 months as per the College of Physicians and Surgeons of Ontario (CPSO) policy. The CPSO provides some important pointers physicians must keep in mind if they choose to implement block fees. For example, patient’s with or without block fees should not get preferential treatment.    

Some useful scenarios:

Patient that cannot afford to pay

The OMA recommends to try to avoid such situations by discussing uninsured fees with the patient before providing the service. Even with a warning, the physician must consider the burden the uninsured service may place on the patient and should be willing to provide options (ie. cost reduction, payment plan).

Third party requests for patient information

Third parties often get their clients (your patients) to sign waivers or consent forms for the release of their medical records. Patients often misunderstand this as consent to release only their medical records pertaining to the one specific injury corresponding to their claim when really they have given consent to release their entire medical file. When third parties call in and provide proof  of this consent, contact the patient first and make sure they understand that you are going to release their entire file. If they are uncomfortable with that, the patient is allowed to withdraw the waiver or consent previously given.

A couple tips:

1.      There are only two government forms which are billable, the Disability Medical Report Form and the Narrative Medical Report (requested for CPP purposes) - all other government forms are not billable, they are the doctor’s responsibility as part of the community.

2.      Insurance companies can be real pushy and sometimes they send a cheque to cover their request- by accepting this cheque you have let them set your fees. Do not accept their cheque and send them your rates and estimated time in advance. Make sure you get pre-authorization for coverage, signed and returned. This approach applies to most third party requests.

3.      Keep patients informed of uninsured service fees; if they are consistently reminded there is no reason for any misunderstandings.

Some common uninsured services:

-          Sick notes for employers or school

-          Medical-legal reports

-          Insurance report forms

Useful contacts:

OMA 1-800-268-7215                     CPSO www.cpso.on.ca

 

Note: All this information was obtained from documents made publicly available by the CPSO and OMA. We are not to be held liable for any occurrences that arise from following our understanding of uninsured services medical billing.