Professional Documents
Culture Documents
Health Insurance Act, R.S.O. 1990, c. H.6; Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5; Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991)
Guide to Third Party and other Uninsured Services, Ontario Medical Association
Dialogue, March/April 2006 New policy sets out block fee expectations
Public and Physician Advisory Service
Services provided by a physician to a patient which are not paid for by OHIP. This includes services provided to uninsured individuals.
Block fee:
A block fee4 is a at fee charged for a predetermined set of uninsured services. This at fee may also be called an annual fee (if it covers a period of 12 months).5
POLICY
A physician cannot charge patients for insured services, including the constituent elements of these services.6 However, a physician may charge a reasonable fee7 for the performance of an uninsured service.
PRINCIPLES
1. The physician-patient relationship is based on trust, and as such, the patient must be condent the physician will put the needs of the patient rst. 2. Good communication is a fundamental component of a trusting physician-patient relationship. 3. Patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship, or pose a barrier to accessing health care services.
DEFINITIONS
Insured services:
Services listed in the Health Insurance Act and the Schedule of Benets for which physicians will be compensated by OHIP,1 provided that the service is being rendered to an insured person.2 In many cases, an insured service is comprised of several constituent elements. Examples of constituent elements of an insured service include the referral of a patient to a specialist and the administrative processing for a new patient being accepted into a practice.3
Physicians must ensure that the fees charged for uninsured services are reasonable, whether the fee is charge individually for services, as provided, or is included as part of a block fee.9 If physicians charge a block fee, the amount charged must be reasonable in relation to the services offered under the block fee. Physicians should refer to the Ontario Medical Association document, Physicians Guide to Third-Party & Other Uninsured Services, for the recommended schedule of fees. Physicians are obligated to let patients know if 10 they will be charging more than this guide.
b) Limitations to Charging Fees11
1. 2. 3.
4.
5.
The services paid for by OHIP are set out in Section 11.2 of the Health Insurance Act and the Schedule of Benefits. An insured person is entitled to insured services under the Health Insurance Act and its regulations. For a complete list of the common and specific elements of insured services that are considered to be constituent elements of the insured medical services, see the preamble of the Ontario Ministry of Health and Long-Term Care, Schedule of Benefits: Physician Services under the Health Insurance Act. Although section 1 (1) 23 of Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), lists charging a block fee as an act of professional misconduct, physicians are able to charge a block fee as this provision has been declared ultra vires and is of no force and effect. This does not prevent physicians from calling a flat fee charge for a predetermined set of uninsured services by another name (i.e., Patient Supplemental Plan), provided that it is not misleading.
listed in regulation12 that a physician may not charge patients for. These include: Services not performed (but a physician may charge for the cancellation of an appointment less than twentyfour hours before the appointment time, or in psychotherapy practice, in accordance with any reasonable written agreement with the patient).13 An undertaking not to charge for a service or class of services.14 An undertaking to be available to provide services to a patient.15
Provide patients with a copy of this policy or the appended information sheet for patients.18 Answer any questions patients may have about the physicians billing policy and about any charges they do not understand. Obtain written conrmation if the block fee option is chosen and maintain it as part of the patients medical record.19 Patients must be given the opportunity to rescind the decision to pay block fees within a week of their original decision (in which case they would be required to pay for services individually, as provided).
b) Patient Access to Care
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 or treat patients preferentially because they agree to pay a block fee. Terminate a patient20 or refuse to accept a new patient21 because that individual chooses not to pay a block fee.22
Physicians who charge for uninsured services are not required to offer the option of paying by block fee. However, those physicians who offer the option of payment for uninsured services through a block fee must also provide patients with the alternative of paying for each service individually at the time that it is provided. To ensure patients are fully informed of their payment options for uninsured services, physicians who offer a block fee must: Offer a block fee in writing,16 indicating the services that are covered by the block fee and providing examples of those (if any) that are not, along with a list of fees17 that will be charged individually for each service should the patient not select the block fee option.
12. 13. 14. 15. 16. Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991). Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 20 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 23.1 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s. 1(1) 23.2. This can include e-communication; however, physicians must provide information to patients by other means (i.e., mailed letter) if their patient(s) do not have access to the internet. Physicians should be aware of the inherent risks in using e-communication with patients and refer to relevant privacy legislation, policies and guidelines for further direction. 17. Physicians cannot charge an administration fee if patients elect to pay per service. 18. If the physician does not provide the patient with a copy of this policy or information sheet, then he or she must inform patients how they may obtain a copy. Physicians can refer their patients to the CPSO for further information about the CPSO policy.
19. For more specific guidance on medical records requirements, refer to the Colleges Medical Records policy. 20. For more specific guidance on ending the physician-patient relationship, refer to the Colleges Ending the Physician-Patient Relationship policy. 21. For more specific guidance on accepting new patients, refer to the Colleges Accepting New Patients policy. 22. Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5, s. 18 (2).
There are two ways a physician can charge patients: (1) for each service, or (2) a block fee. A block fee is a flat fee that physicians can charge for a number of uninsured services. Patients who use a lot of uninsured services may find this a more economical and/or convenient option.
If a physician offers you a block fee, they must do the following:
Let you know if a third party will administer the block fee on their behalf. Give you a week to change your mind about paying a block fee (in which case you would be required to pay for services, as provided).
Physicians cannot:
Allow you to choose whether you would like to pay a block fee, or pay for each service individually at the time that it is provided (pay-per-service). Provide you with the block fee option in writing, including a list of services which would be covered by the fee and examples of those services (if any) that are not covered. Provide you with a list of fees that will be charged individually for each service if you do not select the block fee option. Provide you with a copy of the CPSO policy or this information sheet (or tell you where to get a copy). Get your written conrmation if you select the block fee option. Ensure the block fee covers a period of not less than three months and not more than 12 months. Ensure the amounts charged are reasonable in relation to the services offered. Ensure you agree to the fee before receiving the uninsured service.
Refuse to provide an insured service because you choose not to pay a block fee. Stop treating you because you decide not to pay a block fee. Refuse to accept you as a new patient because you choose not to pay a block fee. Promise or provide preferential services to you if you pay a block fee. Charge an administration fee if you decide to pay-perservice. Charge a fee for services not performed, undertaking not to charge for a service, or being available to provide an insured service.
For more information, please refer to the CPSO Block Fees and Uninsured Services policy on our website at: www.cpso.on.ca under Policies.