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It is important for a physician to realize that he/she is solely accountable for the propriety and accuracy of his/her claims to OHIP. Physicians are legally responsible for ensuring that all claims submitted, including those submitted under a group number (identified to their billing number) reflect the correct fee code(s) for the service(s) that he/she rendered. The ministry may recover money from a physician individually and personally, despite the fact that payment was made to a group account, if that group's claim was made in conjunction with the physician’s solo billing number. This applies equally to hospital groups where fees are paid to the individual physician through a group billing number. It is the physician who is legally responsible for the repayment of any incorrect claims submitted, not the hospital.

A claim is properly payable only for a service that a physician personally rendered or personally delegated and supervised in accordance with the requirements of the Schedule of Benefits for Physician Services. This is equally true whether the claim is submitted under a solo or group billing number.

The following chart of MRC directions indicates that the largest percentage of referrals is based on the A007 Intermediate Assessment fee code.

The Schedule of Benefits for Physician Services defines an Intermediate Assessment (A007) and Minor Assessment (A001) as follows :

Intermediate Assessment : is a primary care service rendered by physicians providing general practice or pediatric services and requires a more extensive assessment than a minor assessment. It requires a history of the presenting complaint(s), inquiry concerning and examination of the affected part(s), region(s), or system(s) or mental or emotional disorder as needed to make a diagnosis, exclude disease and/or assess function.

Minor Assessment : is a visit which involves a direct physical encounter with the patient and includes either or both of the following :

  1. a brief history and examination of the affected part or region or mental or emotional disorder;
  2. brief advice or information regarding health maintenance, diagnosis, treatment and/or prognosis.

The most common reasons cited by the MRC in their directions for the reduction of payment for the Intermediate Assessment are :

  • the physician had billed an intermediate assessment for very minor presenting complaints that only warranted an examination of the affected part or region and hence should have been billed as a minor assessment;
  • the documentation of the intermediate assessments was often lacking pertinent details of the patient's history, functional inquiry, and examination rendered.

In addition to the medical record requirements found in section 37.1 of the Health Insurance Act, the CPSO has developed professional guidelines for office medical records. Appendix B of the Schedule of Benefits also contains information on record keeping as specified in sections 18 & 19 of Ontario Regulation 241/94 made under the Medicine Act, 1991.

Ontario Ministry of Health and Long-Term Care
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