bulletin

Bulletin Number
        4303
Date
        December 23, 1997
Direct inquiries to
         Ministry of Health
         Processing Office


(address below)
Distribution
        Physicians, Hospitals, Clinics, and Laboratories
        and Independent Health Facilities
Subject      GOOD FAITH CLAIMS PAYMENT POLICY
In an ongoing effort to implement the government’s "zero tolerance" strategy for health care fraud and streamline the claims payment process, the Ministry will be shortly ending the "good faith" claims payment policy. This measure, announced by the Minister in September, will place responsibility on the card holder to have a valid card and to carry it at all times. The Ministry will no longer pay for services rendered when the eligibility of the card holder has ended, or for services rendered in a hospital setting when the health number has a missing or incorrect version code. To that end, public advertising will highlight the need for Ontarians to share responsibility for maintaining the integrity of their health cards and, ultimately, the province’s health system.

While this measure was originally to be introduced on January 1, 1998, changes to the legislation which will effectively eliminate "good faith" payments will come into effect March 1, 1998. The Ministry has delayed the implementation of this policy for a short period of time to allow for appropriate communication to the public and providers. Effective March 1, 1998, the Ministry will no longer pay for services rendered when eligibility has ended, or when the health number has a missing or incorrect version code.

This change to the "good faith" payment policy has been made possible with the establishment of three automated validation mechanisms available to providers starting in 1994. At that time, all health care providers were invited to take advantage of the first, Interactive Voice Response (IVR), which makes use of common touch tone telephone technology. Magnetic stripe swipe Health Card Readers (HCRs) were also made available to hospitals in 1994 and large groups in 1995. Overnight Batch Eligibility Checking (OBEC) is currently being piloted to pre-validate those with scheduled appointments. At present, over 17,000 health care providers and facilities have access to the Ministry’s validation systems with at least one type of validation service available to each provider.

Providers who are not now registered to use one of the validation systems may contact the Ministry of Health Validation Help Desk at 1-800-262-6524 or in Kingston at 548-7981 for details or assistance.

All providers have the ability to take the necessary steps to verify the validity of health cards presented or used in billing the Ministry before claims are submitted; therefore, the Ministry is actioning the following two initiatives:

  1. Revoke Regulation 552, section 4 under the HIA
    Regulation 552 will be amended to revoke section 4 of the Regulation. The original intent of this section, to honour claims where premium based/coverage problems existed for the eight digit OHIP number which the health care provider could not know at the time the service was rendered, is no longer relevant.

  2. Discontinue payment of claims for hospital-based services when the health number version code is missing or incorrect for the date of service
    As a result of the 1993 MOH/OMA Agreement, the Ministry was required to pay claims in good faith for hospital-based services when the version code was missing or incorrect for the date of service. In 1996 the Agreement was revoked, but the Ministry continued to pay this type of claim in good faith. Since all hospitals can access validation systems or could have the patient complete a Health Number Release form, this practice is unnecessary.

As is the case now, the Ministry wants to ensure that emergency health services continue to be provided to persons in need. We do recognize that physicians providing services in an emergency department environment may have difficulty in acquiring the correct health number and version code for the patient for billing purposes. The Ministry will provide additional assistance to staff or physicians in an emergency department, so that the release of this information using a Health Number Release form will be accelerated when an invalid validation response has been received.

Enquiries or requests for clarification regarding the elimination of "good faith" payments can be made to your local Ministry of Health - OHIP office.

REIMBURSEMENT FOR MALPRACTICE FEES - 1997 PROGRAM (Physicians only)

Applications for the 1997 Malpractice Reimbursement Program will be mailed to all eligible Ontario physicians on or about January 15, 1998. The application packages will be forwarded by the CMPA; it will include a covering letter, an application form, eligibility requirements, 1997 CMPA fee schedule, your CMPA acknowledgment and a return envelope. Application packages will be mailed directly from the Ministry of Health for those physicians not ensured with the CMPA.

Physicians are reminded that the CMPA acknowledgment is required in their submission to the Ministry for reimbursement. Physicians’ insured with other insuring agents must submit a receipt reflecting full payment of premiums.

Applications must be completed and forwarded to the Ministry by June 30th, 1998 at:

Ministry of Health
Reimbursement of Malpractice Fees
P.O. Box 48
Kingston ON
    K7L 5J3

Enquiries regarding reimbursement of malpractice fees should be directed to your local Ministry of Health - OHIP office.

Office locations
Barrie
30 Poyntz St.
L4M 3P2
Hamilton
119 King St. W
P.O. Box 2280, Stn. A
L8N 4C8
Kenora
220-808 Robertson St.
P9N 1X9
Kingston
1055 Princess St.
P.O. Box 9000
K7L 5A9
Kitchener
Canada Life Square
Main Floor
235 King St. E.,
N2G 4N5
 
London
217 York St., 5th FloorP.O. Box 5700
Terminal A
N6A 1B7
 
Mississauga
201 City Centre Dr.
P.O. Box 7020, Stn. A
L5A 3M1
North Bay
101-447 McKeown St.
P1B 9S9
Oshawa
Exec. Tower,
Oshawa Centre.
419 King St. W.
P.O. Box 635 L1H 8L4
Ottawa
Fuller Building
75 Albert Street
K1P 5Y9
Owen Sound
981 2nd Avenue E.
N4K 2H5
Peterborough
550 Lansdowne St. W.
K9J 8J8
St. Catharines
59 Church St
3rd Floor
L2R 3C3
 
Sarnia
452 Christina St. N.
N7T 5W4
Sault Ste. Marie
Roberta Bondar Place
70 Foster Dr., Ste. 100
P6A 6V4
Sudbury
199 Larch St.,
Suite 801
P3E 5R1
 
Thunder Bay
435 James St. S. ,
Suite 113
P7E 6T1
Timmins
38 Pine St. N., Ste. 110
P4N 6K6
Toronto
2195 Yonge St.
P.O Box 1700 Stn. A
M5W 1G9
Windsor
1427 Ouellette Ave.
N8X 1K1
    Head Office
P.O. Box 38
Kingston, ON
K7L 5J2