Final Exam Medical Billing Review (Module 9b) Notes
CPSO Certification and OHIP
- Upon receiving certification from the College of Physicians and Surgeons of Ontario (CPSO), a physician's CPSO number does not automatically become their Ontario Health Insurance Plan (OHIP) billing number for claims submissions.
Billing Agent Responsibilities
- A billing agent should periodically review the General Preamble to ensure claims submissions are appropriate, accurate, and maximize the payable amount to the physician.
OHIP Schedule of Benefits
- The OHIP Schedule of Benefits is a negotiated contract between the Ontario Medical Association (OMA) and the provincial government of Ontario.
- This Schedule includes a list of uninsured services.
- It is legally supported by the Health Insurance Act, Independent Health Facilities Act, and the Commitment to the Future of Medicare Act.
- False Statement: The OHIP Schedule of Benefits is a legal document.
- Physicians are primarily paid through a negotiated fee-for-service structure in their province's Schedule of Benefits.
Provincial Health Coverage
- An individual with provincial health care coverage cannot always receive medical services without payment while traveling anywhere in Canada.
Application for OHIP Billing Number
- To apply for an OHIP billing number, a physician must hold a valid certificate from the CPSO and have an Ontario address.
Deregulated vs Delisted Services
- A deregulated service is not the same as a delisted service.
Commitment to the Future of Medicare Act
- This act supports prohibiting two-tier medicine, extra billing, and user fees in accordance with the Canada Health Act.
Medically Necessary Services
- Medical services deemed necessary at one time do not always remain unchangeable over time.
Modifications to the Schedule
- Physicians wishing to propose modifications to the Schedule should do so through the Physician Services Payment Committee via the appropriate clinical section of the OMA.
Hospital Identification Codes
- Each hospital has a unique 4-digit master or facility code for claims submissions.
Address Changes
- Physicians must advise the MOHLTC of any address change even if they remain in Ontario.
Approval for Unapproved Services
- A physician cannot bill for an otherwise unapproved service without prior approval.
Health Card Renewal
- Individuals are responsible for checking the expiry date on their health card and ensuring renewal before expiration.
Claims Submission Timeline
- Claims must be submitted within 8 months from the service date unless extenuating circumstances exist.
Claim Acceptance Criteria
- Claims will not be accepted unless they meet all criteria set in the Schedule of Benefits.
Patient Audits
- The MOHLTC may contact patients to conduct audits on claim submissions to verify service encounters.
Referrals and Billing
- Physicians cannot bill for consultations when referring a patient to another physician.
Service Codes
- Procedure codes are also known as service codes.
OHIP Responsibilities
- OHIP provides physician billing numbers and coverage for insured services, but not subsidies for uninsured services.
Role of Ontario Medical Association
- The OMA negotiates with the government for insured services and issues educational opportunities but does not publish a list of uninsured services.
Resource Manual for Physicians
- The Resource Manual provides diagnosis codes, procedure codes, and premium codes.
Procedure Code Explanation
- A procedure code relates to the type of service performed by the physician, among other factors.
Schedule of Benefits Reference
- The Schedule of Benefits includes procedure codes, diagnosis codes, and a list of uninsured services.
Procedure Code Prefixes
- "W" indicates a long-term care facility; "A" indicates an encounter in a physician's office; however, "H" does not relate to inpatient encounters.
Ontario Drug Benefit (ODB)
- The ODB covers residents over 65 and those in long-term care facilities.