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Ministry Status: Routine Monitoring and Engagement

Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

Keeping Health Care Providers informed of payment, policy or program changes

To: Physicians, Hospitals, Clinics, and Laboratories

Published by: Health Services Branch

Date Issued: June 7, 2019

Bulletin Number: 4724

Re: OHIP Payment Requirements for Services Rendered Personally and Procedures Delegated by a Physician

Posted Electronically Only

PDF Version 


Important Reminder

Update to Bulletin # 4549 and Bulletin # 4676

OHIP payments are only authorized for services that are rendered personally by the physician or by others who are delegated by a physician to perform a procedure in accordance with the Schedule of Benefits Physician Services (the “Schedule”) requirements for delegated procedures.

It is the physician’s responsibility to ensure that all claims submitted to OHIP meet all requirements for payment, including record keeping requirements.

If at any time a physician becomes aware of an OHIP claim for payment that does not meet the requirements for payment, the physician should correct the claims submission within six months after the service was rendered or report claims errors to the ministry for correction.

Services Required to be Rendered Personally by a Physician for OHIP Payment

Insured services that must be rendered personally by the physician in order to be payable by OHIP include (but are not limited to):

  • assessments;
  • consultations;
  • psychotherapy;
  • counseling;
  • interviews;
  • diagnostic interpretations; and,
  • surgical procedures.

“Rendered personally by the physician” means that the service must be personally performed by the physician and may not be delegated by the physician to any other person.

If this requirement is not met, the service is uninsured and not payable by OHIP.

Procedures Delegated by a Physician

In order for a procedure delegated by a physician to a non-physician (a nurse, nurse practitioner, or other medical assistant) to be payable by OHIP, the requirements on page GP42 of the Schedule must be met, including that:

  • the procedure is performed by a physician’s employee in the physician’s office;
  • the person the procedure is delegated to is properly trained to perform the procedure;
  • the procedure is one which is generally and historically accepted as a procedure which may be carried out by a non-physician;
  • the physician (although he or she may be otherwise occupied), is at all times physically present in the office or clinic at which the service is rendered in order to ensure that procedures are being performed competently; and is available immediately to approve, modify or otherwise intervene in a procedure, as required, in the best interests of the patient.

As an exception, simple office procedures listed in the table on page GP42 of the Schedule (such as, venipuncture, injections and immunizations, casts, etc.) remain insured despite the physician not being present only when all of the conditions described in payment rule 2 on page GP42 are met.

If the requirements for delegated procedures are not met, the service is uninsured and not payable by OHIP

Delegated procedures are not payable by OHIP when performed by an individual who is employed by a facility or organization such as a public hospital, public health unit, industrial clinic, long-term care facility or Family Health Team.

Examples of procedures that may be delegated for the purpose of OHIP payment include (but are not limited to): drawing blood samples, administering injections such as immunizations and vaccinations, and conducting simple office laboratory tests such as urinalysis or urine pregnancy tests.

Record Keeping for Services Rendered Personally and Procedures Delegated by a Physician

In accordance with subsection 37.1 (1) of the Health Insurance Act (HIA), every physician shall maintain such records as may be necessary to establish whether they have provided an insured service to an insured person.

The ministry requires that the patient medical record indicate whether the payment requirements of the service claimed have been met, including that the service was rendered personally by the physician or that the procedure was delegated by the physician.  Where there are concerns regarding who performed a service, the ministry may contact the physician and may request medical records as part of the physician payment review process.

If the medical records do not clearly establish that the physician personally rendered the service or that the service was not delegated by the physician in accordance with the Schedule, the service is uninsured and not payable by OHIP

For delegated services, the medical record must identify who the non-physician performing the service is, and must contain a description of the service performed by the non-physician.

Medical record requirements for OHIP payments are described in section 37.1 of the HIA and in the specific fee code record keeping requirements in the Schedule.  Additionally, there are medical record requirements for physician records in section 18 of Regulation 114/94 made under the Medicine Act.

Questions regarding billing requirements can be directed to CSB Connects at
1-800-262-6524 or SSContactCentre.MOH@ontario.ca as detailed in Bulletin #4708.

Additional Information

Education and Prevention Committee (EPC)

The EPC has published Interpretive Bulletins that provide general advice and guidance to physicians on specific billing matters including Payment Requirements for Delegated Services.  Included within is information helpful in determining who an employee of a physician/physician group is and is not.

The EPC is jointly established by the Ministry of Health and Long-Term Care and the Ontario Medical Association to educate physicians about submitting OHIP claims that accurately reflect the service provided, thereby reducing the need to recover payments for incorrect claims.

College of Physicians and Surgeons of Ontario (CPSO)

The CPSO Delegation of Controlled Acts policy sets professional expectations for physicians about when and how they may delegate controlled acts specified in the Regulated Health Professions Act to an individual that may or may not be a registered health professional.

Fulfilling the College’s professional expectations for delegation does not establish that the OHIP payment requirements for delegated procedures under the Schedule have been met.

This INFOBulletin is a general summary provided for information purposes only.  Physicians, hospitals, and other health care providers are directed to review the HIA, Regulation 552, and the Schedule under that regulation, for the complete text of the  provisions.  You can access this information at e-Laws.  In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.

To view Portable Document Format PDF files, you will need to have Adobe Acrobat® Reader installed on your computer. You can download this free software from the Adobe website.

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY (416)327-4282
Hours of operation: Monday to Friday, 8:30am - 5:00pm

 
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