Dr. Jane Healey faced a tough decision when her OHIP claim for a newborn’s death at a Toronto hospital was denied. The infant passed away due to a genetic condition after 10 days, but Healey opted not to trouble the grieving family by pursuing the matter further.
Speaking to CBC Toronto, Healey mentioned the emotional toll of such cases going uncompensated. She highlighted that many physicians, including herself, are grappling with OHIP billing issues while negotiating a new payment agreement with the province.
Health Minister Sylvia Jones’s spokesperson, Ema Popovic, stated that over 99% of claims are typically paid automatically, showcasing the system’s efficiency. However, the Ontario Medical Association noted that out of the 200 million annual claims, approximately 1.16 million claims face rejection each year.
Healey, who also heads the OMA’s pediatric section, shared concerns about unresolved OHIP billings, especially for complex procedures like limb reattachment surgeries involving multiple physicians. The ministry mentioned that two-thirds of claims requiring manual review are classified as “complex surgical claims,” hindering doctors from pursuing intricate and innovative medical interventions.
In response to the challenges faced by physicians, an arbitrator has tasked both the province and the OMA with finding solutions regarding good-faith payments and manual reviews for intricate OHIP billings. The OMA advocates for reintroducing the good-faith payment system to enable invoicing for patients without valid health cards, such as newborns and critically ill individuals lacking insurance.
Regarding the manual review process, the OMA proposes establishing an OHIP ombudsman office staffed with clinical experts to streamline the resolution of complex billing issues. Dr. Zainab Abdurrahman emphasized that the current review process, which can drag on for months, may deter doctors from engaging in innovative medical practices.
Popovic assured that the province is committed to enhancing the billing system’s efficiency, reducing administrative burdens for physicians, and collaborating with the OMA on modernizing the system further. However, she expressed disappointment over the OMA’s focus on a minor fraction of claims requiring manual review, rather than acknowledging the progress made in supporting physicians.
Failure to reach a consensus by the year’s end could escalate the matter to arbitration as per the arbitration award’s provisions.
