OHIP Information Session for Residents Planning to Practice in cosmetic surgery by benbenzhou


OHIP Information Session for Residents Planning to Practice in cosmetic surgery

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									                        OHIP Billing Process for New
                             Professional Staff

What Do I Need to Get Started?
 CPSO license number
 Practice address

How to Get Started
 You will need to register under the Regulated Health Professionals Act
 Go to www.health.gov.on.ca and click on:
      o OHIP
              Forms and Application
                      OHIP Forms and Applications for Health Care Professionals
                             o Scroll down to the form # 3384-83 and click on the
                                “Registration for Healthcare Professionals” link

   Review the instructions carefully, and submit your completed application to the
    nearest Ministry of Health and Long Term Care office nearest to your primary
    practice. Ensure you print two copies and keep on for your records.

   The district office will come back to you with a schedule of benefits and submission
    of claims

   You can begin practicing right away even without your billing number. However,
    keep track of all of your claims so that you can submit as soon as you receive your
    billing number.

   You have six months from the service date to submit your claims. Claims submitted
    or resubmitted after the six month deadline will be rejected however if you believe
    you have a special situation you can appeal.

   Billings for new physicians must be submitted using Electronic Data Transfer (EDT).

   Claims made by the 18th of the month are paid on the subsequent month, however if
    you submit by noon using EDT on the last day of the month, it may be included in
    next month’s payment.

   Claims error reports are available soon after your submit your information. These
    are claims that OHIP has rejected for errors such as date or birth or version code
    information. Once a claim is returned on this report OHIP no longer has a record of
    the claim. In order to receive payment you must correct the error and resubmit the

   You must be able to produce a record of your claim, your billing day sheet for a
    minimum of seven years and CMPA recommends ten years and you must maintain a
    permanent medical record with a patient encounter ie. the chart.

   Payment models consist of:
       o Alternate Funding Plans (AFP) - all Academic Health Sciences Centres in
         Ontario. Each plan is structured differently.
       o Fee For Service – most commonly used outside AHSC.
       o Salary

   All payment models require you to be registered with OHIP and you must submit

   Some AFP’s, however, require Shadow Billing. Claims are submitted in the usual
    manner to provide proof of deliverables but payment is not made. Physicians in
    these plans receive remuneration based on their AFP contract and not directly based
    on OHIP billing. Some plans with Shadow billing provide physicians with an
    additional payment based on some percentage of the Shadow Billing total.

   The PDF Fees Schedule can be viewed online at:

Types of Medical Services: Insured and Uninsured
1. Insured (Schedule of Benefits)
     Fee types consist of:
        Professional Fees
        Technical Fees
        Premiums & Add on fees

       3 classes
         OHIP
         Reciprocal – claims for patients from all other provinces except Quebec
         WSIB (claimed through OHIP but flagged as WSIB)

2. Uninsured
     Can be an uninsured service (ex. Filling out a form, Botox injections) or can be
       an uninsured patient (out-of-country, RCMP, Mennonite). These claims can be
       billed directly to the patient

    The General Pre-Amble in the Schedule of Benefits is a must read. It contains
    definitions of age, various assessments, statutory holidays, rules for time related
    services, etc.

OHIP Requirements for the Medical Record Include…
      1. Proof that the service was provided
      2. The service billed has to be the same service that was provided
      3. The service has to be medically necessary. Work that is not medically
         necessary is uninsured work. This includes work for travel services, lab work
         for cosmetic surgery, etc.

     Read the information on premiums and rules for hospital care, as there        are
    three hospital codes, rules for surgical assessments, etc. Information          can be
    located at www.health.gov.on.ca.

Delegated Acts
 You can bill for services if you are supervising the person performing the procedure.
   This person must be qualified and must be a direct employee. Assessments can not
   be delegated to anyone. You must have had face to face contact with the patient
   before you can delegate the procedure.

   Included in the surgical fee and service are:
         Booking of surgical appointments
         Obtaining and reviewing information ie. reading MRI’s prior to surgery
         Obtaining consent and reviewing information ie. reading MRI’s prior to
         Obtaining consent

   You can not bill separately for these services. Be knowledgeable about what is

   Assessments can only be billed as assessments. You must have face to face
    contact between the physician and patient. It can not be over the phone. The
    encounter must be documented on the chart.

Claims for Consultation
 Family General Practice consultations require a full general assessment.

   A written request is needed from the referring physician and a written response to
    the referring physician is required. If the consulting physician requests to see the
    patient at a later date, it is not to billed as a new consultation.

   For Internists you can only bill one consult per year for the same diagnosis

Time Based Assessments
 Counseling, psychotherapy and group therapy are billed in units of 30 minutes. To
   claim 1 unit, you must complete 20 minutes. Subsequent units must be at least 16
   minutes. You must record start and stop times.

 Premiums are available for the following situations:
    Special visits to patients
    Procedures during non-business hours
    Weekends and holidays
    Trauma patients (based on age and based on chronic conditions)

Surgical Preamble
 Assessment can only be billed on the day the decision to operate occurs, regardless
   of when the surgery is done.

   Assessment can not be billed on the day of the surgery, except for patients who
    present in Emergency and same day operation is required (major pre-op exam is

 WSIB injuries must be claimed as WSIB or they will be determined to be uninsured.

 Removal of benign moles – you remove it, send it to Pathology, determine it is not an
   ordinary mole, bill OHIP and give the money back.

 Work completed by a resident/staff can be billed, provided the resident/staff has
   been identified to the patient and the resident/staff has reviewed the findings.

   Can not bill for more work that could be done personally. Example: If you have
    three residents who see three patients and the consultant sees one patient all in the
    same hour….can you bill for four patients? Answer: No.

Can you Bill for Telemedicine/Videoconference?
 Codes in the outpatient setting are the same as in your office.

   Nobody in the same specialty can bill for subsequent visits. If a post-surgery patient
    needs to see the surgeon and they come back at night, you can not bill for the post-
    op visit, however, you can bill for the premium at night.

   You can bill for 2 assessments per year provided the diagnosis is different.

Source: Smucker, Dr. Ron, “OHIP Billing: Setting Up a Practice”
        Presentation notes from the University of Western Ontario, Schulich School of
        Medicine and Dentistry and Postgraduate Medical Education Academic Half-Day,
        January 2008


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