Workplace Safety and Insurance Board (WSIB) Medical Billing

The purpose of this blog entry is to clarify when and how doctors should be billing WSIB (formerly known as Workers Compensation Board (WCB)). In this blog I will assume that you have a basic knowledge of medical billing. If there is anything you need clarification on, please feel free to contact us.

From what I understand, part of the WSIB role is to provide lost wages to workers who have been injured on the job and to assist those workers in the “return to work” process.

In order to distinguish whether you are to bill the Ministry of Health and Long Term Care (MOHLTC/OHIP) or WSIB you must identify whether the patient was injured on the job.  If the patient implies in any way that their injury occurred at work you should be billing WSIB. To bill WSIB, you would still proceed to bill OHIP the exact same way as you would if the injury didn’t occur at work however, you should bill under WCB rather than the commonly used HCP (Health Care Pool). In addition, you will need to fill out some initial forms/reports and submit them to WSIB.

NOTE: Physicians should register with the WSIB in order to receive their unique 9 digit number which is to be used on reports. This number is important as it serves as your invoice to WSIB. When you submit a form/report you will be paid by WSIB using this 9 digit number.  

The forms that are commonly completed when you have a patient injured on the job are Health Professional Form 8 (first report), Progress Report Form 26 (only if requested by WSIB), and Functional Abilities Form (FAF) for timely return to work (requested by employer/employee but paid to be completed by WSIB). As a tip, all three forms can be mailed/faxed/electronically submitted but for electronic submission the pay is higher (ex: Mail- $65 vs. Electronic-$85) which is a nice incentive to go paperless. You can also be asked to do a telephone interview, an in person interview or to write a narrative report; of course you are paid for complying with any of these requests.

Some useful scenarios:

Patient with no MOH number

You get a patient that was injured on the job, and you go to submit the claim to OHIP under the WCB category when you realize the patient does not have a Ministry of Health (MOH) number. In this case you would bill WSIB directly using their Provider Payment Request Form. Indicate on the form why you used the form (ex: No MOH number).

Providing uninsured health care to patient injured on the job

If the patient was injured on the job and requires uninsured health care (anything not covered by MOH) then you can fill out the WSIB Provider Payment Request Form to get pre-approved for payment from WSIB for the uninsured health care you will be providing. WSIB will most likely provide you with fee code to use to bill for the uninsured health care.

Patient does not want to claim WSIB

If the patient implies in any way they were injured on the job, but they decide they do not want to submit a claim to the WSIB then they must incur all medical costs. You cannot bill OHIP under HCP. This isn’t uncommon as some patients are afraid of submitting a claim in fear of the consequences of their employer.

A couple tips:

1.      When a worker is injured on the job either the injured worker (the employee) or the employer can file a claim with the WSIB. As soon as the claim is filed it is implied that the patient provides consent to the WSIB to seek out all medical records required to adjudicate the file. Physicians take note of this and pass on the message to your staff. When the WSIB calls for the relevant patient records, you do not need to acquire your patient's consent prior to providing the information to the WSIB.

2.   Be aware- if the employer or the injured employee has not submitted a claim to the WSIB but you still proceed to bill WSIB and fill out the applicable forms, you will not be paid. WSIB must match your claim with a claim entered by the injured employee or employer.

3.      All provinces have their own WSIB or its equivalent. You should be billing the WSIB of the province within which the employer is located.

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