Billing for uninsured services

There are some practical guidelines physicians can follow when billing a patient directly for uninsured services, to help make the process as comfortable and efficient as possible. In order to establish an office policy on billing for uninsured services, physicians should first determine:

• Those services for which patients will be directly billed*
• The fees attached to those services
• Any exemptions, such as for seniors or those on fixed-incomes
• Bookkeeping and collection procedures

Examples of some common uninsured services include:

• Missed appointments or procedures if less than 24 hours notice has been given (an exception being psychotherapy practices where a reasonable written agreement existsbetween the patient and physician)
• A service that is solely for the purpose of altering or restoring appearance
• Providing a prescription to an insured person if the person or person’s personal representative requests the prescription and no concomitant insured service is provided
• Completion of third party reports and forms

Note that Section 24 of Regulation 552 under the Health Insurance Act precludes a physician from billing a patient or third party:

• For keeping or maintaining appropriate physician records
• For conferring with, or providing advice, direction, information, or records to physicians or other professionals concerned with the health of the insured person
• For obtaining consents or delivering written consents; and/or
• 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 care for insured services, etc.)

A physician’s office policy on direct billing for uninsured services must be specific and detailed so that it is fully understood by staff and patients. It should also allow sufficient flexibility to adapt to 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. When billing directly for services provided, physicians should: 

1. Establish and maintain a simple and clear office policy and procedure for direct billing
2. Inform staff of this policy and procedure and keep them apprised of any changes
3. Always discuss fees with the patient before providing the service
4. Collect payment from patients at the point of service as often as possible
5. Maintain up-to-date accounts

Physicians should familiarize themselves with pertinent College of Physician and Surgeons of Ontario policies, such as:

• Third Party Reports
• Uninsured Services: Billing and Block Fees

Resources

• Implementing an Uninsured Services Program

Patients and their ability to pay for service

There are some instances where patients claim economic hardship and an inability to comply with the fees they are charged for the uninsured services rendered. It is important for OMA members to realize these are suggested rates. When calculating fees, consider the financial burden that such charges might place on the patient and whether it is appropriate to reduce, waive or allow flexibility based on these considerations as applied to the circumstances of each case. The Canadian Medical Association’s Code of Ethics states under Paragraph 16 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, and will be prepared to discuss the fee with the patient.” Furthermore, the Medicine Act prohibits physicians from “charging a fee that is excessive in relation to the services performed.”

Collecting fees

Physicians may take action to collect fees owed to them, which may include physicians or their office staff contacting patients or hiring a third party (i.e., collection agency) to assist in the process. Physicians who are considering ending the physician-patient relationship due to an outstanding balance must comply with the expectations set out in the CPSO’s Ending the Physician-Patient Relationship policy.

Timeliness of response

The CPSO Third Party Reports policy states that physicians should complete and submit third party reports within 45 days, unless a timeline for these activities has been specified by legislation or a specific legal requirement.** If physicians are unable to comply with this timeframe, either due to the complexity of the report, or for another appropriate reason, physicians should discuss the matter with the third party and reach an agreement for a reasonable extension.

Code of ethics

The responsibilities of an ethical physician to the patient are stated in the Code of Ethics (revised by the Canadian Medical Association in 2004) and include the following: An ethical physician will “provide the patient or a third party with a copy of his or her medical record, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others."

In addition, Section 1.17 of Ontario Regulation 856/93 made under the Medicine Act, 1991 states that it may be considered professional misconduct to fail “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."

*Not all fees are up to the physician’s discretion (e.g. WSIB services).

**The Personal Health Information Protection Act specifies that an individual has a right of access to a record of personal health information and that the health information custodian shall give the response required as soon as possible in the circumstances but no later than 30 days after receiving the request (unless a time extension has been put in place).

A block fee is defined as a flat fee charged by a physician for a predetermined set of uninsured services during a predetermined period of time (no less than three months and no more than one year). Not all physicians are in a position to charge a block fee due to the nature of their practice and specialty. Physicians are not required to offer a block fee option; patients can be charged on a fee-for-service basis for uninsured services. Physicians who do choose to offer a block fee must also offer uninsured services separately at individual costs to patients. Patients cannot be required to pay a block fee.

The CPSO policy on block fees states that physicians may use third party companies to assist them to administer a block fee or payment for uninsured services. Any communication to patients should identify the fact that a third party was involved. Third parties who are asked to administer block fees or payment for uninsured services are acting on the physician’s behalf. Physicians are responsible for ensuring these companies adhere to the same standards required of physicians.

The policy also states that patient decisions regarding payment for uninsured services must not affect their ability to access health care services. Physicians must not:

• Require that patients pay a block fee before accessing an insured service
• Offer to treat patients preferentially because they agree to pay a block fee
• Terminate a patient or refuse to accept a new patient because that individual chooses not to pay a block fee

Implementing an Uninsured Services Program: A Guide for Physicians offers further information on how to implement an efficient and effective Uninsured Services Program in a physician office, including relevant policies and interpretation of regulations applicable to the implementation of such programs.

Per the OMA reference guide, Implementing an Uninsured Services Program: A Guide for Physicians, the following suggested steps will help physicians to implement a successful Block Fee Billing Plan.

Step 1: Inform patients of the BFBP

The first communication about the BFBP provided to patients should include:

• A personalized letter informing the patient of the change in billing practices regarding uninsured services and that choosing to be in the BFBP is optional
• The effective date for the new policy
• A list of the uninsured services that will be covered in the BFBP
• A timeframe for the BFBP cycle (e.g. Jan. 1 to Dec. 31). The BFBP cannot cover a period of less than three months or more than twelve months
• This initial communication should not include a request for payment

Step 2: Provide an enrolment form for the BFBP

A follow up communication should be sent to patients approximately two to three weeks following the first, and should include:

• A follow-up personalized letter
• A BFBP enrolment form, which also indicates payments options
• The date that the BFBP will become effective
• A copy of the physician’s Uninsured Services Fee Schedule (developed by the physician
• Information on how patients can access the CPSO policy on Block Fees and Uninsured Services. It is mandatory to provide this policy to patients when offering a BFBP4

Step 3: Update the patient record

• Once the BFBP enrolment form is completed and returned by the patient, indicate the preferred payment option in the patient’s record
• Code each patient record by indicating those who have enrolled and those who prefer to pay for services individually, as they are rendered

Step 4: Develop a standard process for charging for uninsured services

• Use a “charge slip” for billing and collecting for each uninsured service provided to patients not enrolled in the BFBP. Physicians should inform the patient or the person(s) financially responsible about such charges prior to rendering the service
• Ensure that the practice has equipment that permits different payment methods, (e.g. point-of-service for debit or credit card)

Step 5: Remind and renew the BFBP

• When a patient, who is not a member of the BFBP, is billed for an uninsured service, remind the patient about the availability of the program
• Renewing the BFBP for those already enrolled, and initiating Step 1 for those who have not yet enrolled, should begin approximately two months prior to the chosen annual renewal date
• In accordance with the regulations under the Medicine Act regarding professional misconduct, the fee for a patient joining the plan mid-year should be prorated to ensure that the patient is being charged a reasonable amount for the block fee

Step 6: Evaluation of the BFBP

Review the BFBP annually to ensure:

• It adheres to provincial regulatory guidelines
• A physician’s personal “Uninsured Services Fee Schedule” is updated as per the OMA Physician’s Guide to Uninsured Service

Many patients are surprised to discover that not all of their medical needs are covered under the Ontario Health Insurance Plan, and that they must pay their provider directly for certain uninsured services. This misunderstanding can lead to situations that are frustrating and uncomfortable for both the patient and physician, as well as medical office staff — particularly if the patient learns about the cost after the service has been rendered. To prevent this from occurring, there are strategies that can be employed to make billing and collecting payment for uninsured services more efficient:

• Always discuss the fees and, where applicable, an expected completion date with the patient/third party in advance of providing the services
• If physicians charge patients for uninsured services, the CPSO states that a list of fees should be made available to the patient. This list must be available regardless of whether the fee will be paid on a per service basis or in the context of a block fee. Consider displaying a list in the patient waiting area
• Have patients sign a letter of acknowledgement, confirming that they have been informed of, and understand the uninsured services policy
• When invoicing patients/third party, be sure the services have been itemized. It is considered professional misconduct for failing to itemize an account for professional services, if requested to do so by the patient or the person or agency who is to pay, in whole or in part, for the services, or if the account includes a commercial laboratory fee. In addition, physicians should issue receipts for all cash payments and ensure that these transactions are properly documented
• Don’t hesitate to contact the third party (or the patient, where applicable) requesting information in the event the request is unclear, or if the request is unreasonable. It’s not unusual for a third party to request a “copy of the patient’s file” when in reality, the third party is looking for a specific piece of information. This saves the physician from performing unnecessary work and results in a more manageable fee to the requesting party
• Consider arranging a payment plan with the patient that aligns with their financial means
• Consider dedicating a section in the office newsletter and/or office website to the issues and costs associated with uninsured services provided by your practice. Include information on which methods of payment will be accepted by the practice (e.g. debit, credit), and encourage patients to ask questions and obtain more information from the physician or office staff. A patient information pamphlet can also be created and distributed, communicating the uninsured services offered and their respective fees
• Educate the office team about uninsured services so that they can educate patients. Providing staff with a clearly laid out uninsured services fee listing, and ensuring they are well-versed on payment procedures, is an effective and direct method of communicating with patients. This process will involve counselling staff on which questions to ask patients at the time of rostering, and/or when an appointment is being booked, so that staff are better equipped to advise patients about any associated uninsured fees. Staff should also inform patients about acceptable methods of payment so that patients are better prepared to pay at the time of the appointment

Physicians who are HST registered are required to charge and collect tax at a rate of 13 per cent on any taxable supplies (other than zero-rated supplies or exempt supplies) of goods and services they supply in the province of Ontario.

All physicians, whether registered or not, are required to pay HST at a rate of 13 per cent on the purchase cost of most of their supplies (other than payments to employees). For those physicians not exceeding $30,000 in taxable sales, HST registration is voluntary. Members should be aware that once registered as collectors and remitters of HST, they must continue to file reports even if the HST falls below the $30,000 threshold.

Consequently, if a physician retires or significantly reduces his or her supply of HST-taxable services, he or she will have to formally de-register as a HST remitter to be able to cease providing monthly reports to the Canada Revenue Agency. It is suggested physicians consult with an accountant prior to registering for HST.

Amendments to the Excise Tax Act

The Excise Tax Act was amended as of March 21, 2013 to clarify that a supply that is not a “qualifying health care supply” is deemed not to be an exempt “health care service”. A “qualifying health care supply” is defined to mean “a supply of property or a service that is made for the purpose of:

• Maintaining health
• Preventing disease
• Treating, relieving or remediating an injury, illness, disorder or disability
• Assisting (other than financially) an individual in coping with an injury, illness, disorder or disability
• Providing palliative health care”

The CRA states that the intent of these changes was to clarify that GST/HST “applies to reports, examinations and other services that are not performed for the purpose of the protection, maintenance or restoration of the health of a person or for palliative care.” While further clarifications continue to be sought from the CRA, the CRA has indicated that where the primary purpose of a supply is the protection, maintenance, or restoration of health, the supply will be exempt from HST. A supply may have a dual purpose (e.g. an exam whose purpose is both to promote health as well as to provide information for a financial form), but the health benefit cannot be incidental or ancillary to the primary purpose.

Read more about the OMA's general guidelines on HST and uninsured services.

There are several ways a physician can calculate their rates and fees for uninsured services (including those requested by third parties).

In calculating fees for uninsured services, the physician should take into consideration, as circumstances dictate, some or all of the following factors:

• Nature and complexity of the matter
• Experience and expertise of the physician
• Time spent with and/or on behalf of the patient
• The cost of materials not included in the fees for insured services.

The OMA suggests fees for a number of more common forms and services that are typically requested by third parties. However, there are forms, reports and services that are not specified, and in these cases physicians can use one of the following methodologies to establish an appropriate fee.

At the physician’s cost:

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. Examples of services that are often billed at the physician’s cost:

• Toll charges for long-distance telephone calls
• Preparing/providing a drug, antigen, antiserum or other substances used for treatment (but not used to facilitate the procedure/examination)
• Preparing or providing a device that is not implanted by means of an incision and that is used for therapeutic purposes (e.g., IUD). 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 OHIP Schedule of Benefits, in which case the patient cannot be charged a fee

Establish an hourly rate

In the absence of a specific fee recommendation for an uninsured service, physicians can consider establishing an hourly rate to assist in determining the appropriate fee. Given the diversity of physician practices and nature of uninsured services provided, the OMA does not have a suggested hourly rate. As such, it is incumbent upon the physician to establish their own
hourly rate.

One way to determine an hourly rate could be based on an individual’s gross annual income. A possible source for annual gross income could be from your annual income tax statement.

The OMA does not recommend a standard, suggested hourly rate that applies to all physicians.

Another example of determining an hourly rate is to use an average day’s income divided by the hours worked.

Resources

• 2024 Physicians’ guide to uninsured services.
• The OMA's 2024 Schedule of Fees.
• The OMA's suggested fee for uninsured services calculator.

The Interim Federal Health Program provides limited, temporary coverage of costs related to health care for specific categories of people, including protected persons, refugee claimants, rejected refugee claimants and other specific groups. The IFHP provides several types of coverage:

• Health care coverage
• Expanded health care coverage
• Public health or public safety health care coverage
• Coverage for persons detained under the Immigration and Refugee Protection Act
• Coverage of the cost for immigration medical examinations

The program is funded by Citizenship and Immigration Canada and administered by Medavie Blue Cross. Physicians are reimbursed at OHIP rates.

Health care providers are required to verify patients’ IFHP eligibility (which includes the patient’s coverage type and the service requested) with Medavie Blue Cross before providing the service because the patient’s eligibility may cease or coverage can be modified without notice should their immigration status change. A date printed in the “valid until” date field of the patient’s Interim Federal Health Certificate of Eligibility is not significant proof of eligibility.

For additional information about the IFHP, types of coverage and how to register as a provider, refer to the IFHP Provider Portal.

General inquiries re: IFHP can be made directly to Medavie Blue Cross:
By email: CIC_Inquiry@medavie.bluecross.ca
By phone: 1-888-614-1880

Physicians are not required to participate in the Interim Federal Health Program. If choosing to participate, physicians are not permitted to bill the patients directly.

The OMA develops a guide for physicians with advice on billing for uninsured and third-party services, including completion of forms. The 2024 Physicians Guide to Uninsured Services provides suggested fees for completing forms. The following table highlights some examples of uninsured or third-party forms:

There are various forms that are required by legislation to complete, which may not be charged to the patient, and may not be submitted to OHIP for payment. Section 24 of the Health Insurance Act R.R.O. 1990, Regulation 552 Amended to O. Reg. 352/04 stipulates what is considered an “uninsured” service and what cannot be submitted to OHIP for payment.

Some examples of unremunerated forms include:

• Application for accessible parking permit (002-SR-LV-129E)
• Accessible transit eligibility application forms
• Children’s Aid Society forms (on behalf of a child)
• Ministry of Health forms (ADP Assistive Device forms, etc.)