Consultant Requests a Referral Letter for Subsequent Visit: If a consultant physician decides that he/she will not see patients for medically necessary follow-up visits unless an additional written request is received from the primary care physician, that subsequent visit still does not fulfill the requirements of a consultation fee for the purpose of claims to OHIP. When it is medically necessary to assess the response to treatment/advice or to monitor the patient's clinical condition, an assessment fee, and not a consultation fee is the only appropriate claim.

Referrals by Non-Medical Health Care Professionals:On occasion non-physician practitioners, such as chiropractors, optometrists, or nurse practitioners, request the opinion of a physician or transfer the care of a patient to a physician. The service provided by the physician in such circumstances cannot be claimed to OHIP as a consultation, but must be claimed using the appropriate assessment fee. A consultation can only be claimed when the opinion of the consultant physician is requested by another physician. This policy is not new and has been reflected in previous Schedules.

Requests for Diagnostic Tests:When a physician orders a diagnostic test that will be performed by a second physician, or his/her delegate, the only claim for the service that can be submitted by the second physician is that for the diagnostic test. It is not appropriate to claim a consultation fee or assessment fee when the request from the referring physician is only for the diagnostic test.

However, in some cases the clinical opinion of the physician performing the diagnostic test may also be requested. Such a situation also requires a distinct written request for the consultation. It is not appropriate for physicians who perform diagnostic tests to require that the request for the test also be accompanied by a request for a consultation.

Fee for referral letter:No fee can be charged to the patient for making the written request. Such a service is a constituent element of the insured service fee.

Recourse:A regular pattern of submitting claims for consultations where the requirements of a consultation have not been met may be seen as a willful act. When it appears that a physician may be intentionally submitting incorrect accounts to the Plan, consideration by the Ministry for fraud investigation is possible.

Refusal of Care:In matters where the provision of care is being compromised by inappropriate requests for written referrals, the Ministry of Health has no jurisdiction and will direct any such complaints to the College of Physicians and Surgeons.

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Ontario Ministry of Health and Long-Term Care
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