Can Doctors Black List Patients If They Owe Doctor Money

Uninsured Services: Billing and Block Fees

Approved by Quango: November 2017
Reviewed and Updated: May 2010, November 2004, September 2000

Companion Resources:

• Advice to the Profession
• Patient Data Canvas | Services non assurés : Feuille de renseignement à 50'intention des patients sur la facturation et les honoraires forfaitaires

Other References:

• Dialogue, Issue 4, 2017: Policy addresses "upselling"concerns

Policies of the College of Physicians and Surgeons of Ontario (the "College") set out expectations for the professional behave of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and instance law, they will be used by the Higher and its Committees when considering physician practise or conduct.

Within policies, the terms 'must' and 'brash' are used to articulate the College's expectations. When 'advised' is used, it indicates that physicians can utilize reasonable discretion when applying this expectation to do.

Additional information, general communication, and/or best practices tin be found in companion resource, such as Advice to the Profession documents.

Definitions

Insured services: Services, including their elective elements, listed in the Health Insurance Act and the Schedule of Benefits that are publicly funded under the Ontario Health Insurance Programme^ane (OHIP), on the condition that the service is being provided to an insured person².

Uninsured services: Services provided by physicians that are not publicly funded nether OHIP (e.g., prescription refills over the telephone, copy or transfer of medical records, etc.). This includes services provided to individuals not insured under OHIP.^three

Block fee: A fee that is charged to patients to pay for the provision of one or more uninsured services from a predetermined set up of services during a predetermined menses of fourth dimension.⁴ At the time of payment it will not exist possible for the patient to know how many, if whatsoever, services will exist needed.⁵

Policy

1. Physicians must not charge:
   1. for the provision of insured services (including the elective elements of insured services),⁶
   2. whatsoever amount in excess to what OHIP has paid or will pay,^seven
   3. for services not performed,^eight
   4. for an undertaking to be available to provide services to a patient,⁹ or
   5. for uninsured services where the government has agreed to remunerate physicians for the provision of these services.^ten
2. Physicians are entitled to charge for the provision of uninsured services, but must do so in accordance with this policy, other relevant policies, and relevant legislation.^eleven

Setting Fees that are Reasonable

3. Physicians must ensure that the fees they charge for uninsured services, including block fees, and appointments that are missed or cancelled without the required notice, are reasonable.¹² In doing so physicians must:
   1. ensure that fees for individual uninsured services are commensurate with the nature of the services provided and the physicians professional costs, giving consideration to the recommended fees set up out in the Ontario Medical Association's Physicians Guide to Uninsured Services ("the OMA Guide") and any recommended fees gear up out by professional specialty clan(s);
   2. ensure that the amount charged for a cake fee is reasonable in relation to the services and the flow of time covered by the block fee; and
   3. when setting fees for appointments that are missed or cancelled without the required observe, consider what would constitute reasonable cost recovery and what would deed as a reasonable deterrent to patients, recognizing the lost opportunity costs to other patients when appointments are missed or cancelled without the required notice.
4. Physicians must as well consider the patient's ability to pay^thirteen when charging for uninsured services, individually or by block fee, charging for appointments that are missed or cancelled without the required notice, and collecting outstanding balances. In particular, physicians must consider:
   1. the financial brunt that these fees might identify on the patient and whether information technology would exist advisable to reduce, waive, or allow for flexibility on compassionate grounds; and
   2. granting exceptions for appointments that are missed or cancelled without the required notice when information technology is reasonable to practice so (e.chiliad., first or isolated incident, intervening circumstances, etc.).

Communicating Fees

5. Physicians must ensure that the patient or 3rd party^fourteen is directly informed of any fee that will be charged prior to providing an uninsured service, except in the example of emergency intendance where it is impossible or impractical to do so.
6. Prior to providing an uninsured service, physicians must also notify the patient or third party if they charge more than the OMA Guide and the excess amount that will exist charged.¹⁵
7. While physicians may rely on staff to provide information almost fees and to answer questions, physicians must exist available to offer explanations and/or reply questions most their fees.
8. Physicians are advised to:
   1. back up patient educational activity by posting a full general notice in their part listing fees for common uninsured services (although this is not a substitute for direct informing patients or third parties of the fees associated with uninsured services), and
   2. direct patients to the College'southward Patient Data Sheet on Uninsured Services: Billing and Block Fees.

Charging for Missed or Cancelled Appointments

9. Physicians are permitted to charge for an appointment that is missed or cancelled with less than 24 hours' notice (or in a psychotherapy practise, in accordance with whatever reasonable written agreement with the patient).¹⁶ Physicians who intend to charge patients in these circumstances must:
   1. have a system in place to facilitate the cancellation procedure,
   2. ensure the patient was informed of the cancellation policy and fees in advance, and
   3. have been bachelor to run into the patient at the time of the date.

Providing an Invoice

10. Physicians are brash to always provide an itemized invoice for any uninsured services that are provided and for which fees are paid,¹⁷ but must provide an invoice when asked for one.¹⁸

Combining Insured and Uninsured Services

11. Physicians who suggest or provide insured and uninsured services together or offering uninsured services as an alternative or as a complement to insured services must:
    1. conspicuously communicate which services or elements of a service are associated with a fee and which are not;
    2. describe the differences between the insured and uninsured options in a articulate and impartial manner, providing clear and unbiased information nearly the options available to the patient;¹⁹
    3. ensure that if their exercise structure leads to different wait times for the insured and uninsured services they provide, they are compliant with Delivery to the Future of Medicare Act, 2004 prohibitions relating to preferential admission to insured services; ²⁰ and
    4. place the interests of their patients above their own by managing any real or perceived conflicts of interest that might ascend in this context, including not referring a patient to a facility in which they or a member of their family has a financial involvement without start disclosing that fact, and selling or otherwise supplying whatever medical appliance or medical product to a patient at a profit.²¹

Collecting Fees and Outstanding Balances

12. Physicians may take activeness<²² to collect any outstanding fees owed to them, but must do so in a professional fashion and in accordance with privacy legislation.²³
13. Physicians who are because catastrophe the medico-patient relationship due to an outstanding residue must comply with the expectations set out in the Ending the Doc-Patient Relationship

Offering a Block Fee

14. A block fee may non exist appropriate in all do settings. Equally such, physicians must consider the nature of their practice and specialty earlier offering a block fee.²⁴
15. Physicians must non charge a cake fee in order to encompass authoritative or overhead costs associated with providing insured services.²⁵
16. Physicians must ensure the block fee covers a flow of not less than 3 months and non more than than 12 months.
17. Physicians offering a block fee must always provide the patient with the option of paying for each service individually and must ensure that patient decisions regarding whether to pay a block fee do not affect their power or the ability of other patients in the practice to access health-intendance services. In particular, physicians must not:
    1. require that patients pay a cake fee earlier accessing an insured or uninsured service,²⁶
    2. treat or offer to treat patients preferentially considering they concur to pay a block fee, or
    3. end a patient or decline to accept a new patient because that private chooses not to pay a block fee.²⁷
18. To facilitate patient choice, physicians must:
    1. offer a cake fee in writing and in so doing:
       1. betoken that payment of a cake fee is optional and that patients may cull to pay for uninsured services as they are provided;
       2. indicate that the patient'south decision to pay for uninsured services individually or through a block fee will non affect their ability to access wellness-care services;
       3. place those services that are covered by the block fee, provide a list of fees that will be charged for each service should the block fee option not be selected, provide examples of those services (if any) that are not covered, and betoken for which services (if any) the fee is simply reduced if the block fee option is selected;
       4. use plain language and requite consideration equally to how to accost linguistic communication and/or communication barriers that may impede patients' ability to empathise what is being offered;
       5. refrain from using linguistic communication that is or could be perceived as coercive or suggestive that without payment of the cake fee, services will exist express or reduced, or that quality of intendance may suffer;
       6. invite patients to consider whether payment of a block fee is in their best interest given their needs or usage of uninsured services; and
       7. direct patients to the College's Patient Information Canvass on Uninsured Services: Billing and Block Fees;²⁸
    2. ensure that patient questions about the block fee are answered, ensure that help is available to patients to determine if the cake fee is in their best interest, and be available to answer questions or provide assistance upon request; and
    3. obtain written confirmation if the block fee selection is chosen and maintain it as part of the patient'due south medical record.

19. Physicians must give patients the opportunity to rescind their decision to pay a block fee within a week of the original decision. If the patient does rescind their decision, physicians must refund the amount charged for the block fee before then charging the patient individually for any uninsured services already provided.
20. If the md-patient relationship ends, physicians are advised to consider whether it would exist reasonable to refund a portion of the cake fee, considering both the time remaining and the services provided to date.

Using Third Party Companies

21. Physicians using a third party to administer and manage their block fee or payment for uninsured services, must ensure that:
    1. any communication between the third party and patients identifies the third political party by proper name and indicates they are acting on the physicians behalf; and
    2. the third party adheres to the same standards required of physicians, including this policy, other relevant policies, and relevant legislation.

Endnotes

^i. The services paid for by the Ontario Health Insurance Plan (OHIP) are set out in Section 11.2 of the Health Insurance Act, R.Due south.O. 1990, c. H.six (hereinafter, Health Insurance Act) and the Schedule of Benefits: Physicians Services nether the Wellness Insurance Human action (hereinafter, Schedule of Benefits).

^2. An insured person is entitled to insured services as per provincial legislation and regulations. In Ontario the Wellness Insurance Act and its regulations set out the definition of insured persons who are covered by OHIP. The College acknowledges that individuals not covered by OHIP may be covered by other publicly funded insurance programs or by another provincial health insurance plan. As there are unique requirements, processes, and challenges related to each of these situations, for the purposes of this policy, the definitions of insured and uninsured services or persons are framed in relation to the Wellness Insurance Act and OHIP.

^3. See the Schedule of Benefits, Section 24 of the General R.R.O 1990, Regulation 552 enacted under the Wellness Insurance Act, as well every bit the Ontario Medical Association'southward Physician's Guide to Uninsured Services for more than information about the specific services that are or are non covered by OHIP.

^4. This does not prevent physicians from calling the fee past some other name (i.eastward., Patient Supplemental Plan, Block Billing Plan, etc.), provided that information technology is not misleading.

^5. Adjusted from Department xviii(4) paragraph (a) of the Delivery to the Futurity of Medicare Act, 2004, S.O. 2004, c.5 (hereinafter, CFMA, 2004).

^{half dozen.} See the "Constituent and Common Elements of Insured Services" of the Schedule of Benefits and Sections ten(i) and (3) of the CFMA, 2004.

^7. Encounter Sections 10(1) and (3) of the CFMA, 2004 too as Sections xviii and 19 of the Canada Health Deed, R.S.C., 1985, c. C-6.

^8. Section 1(1) paragraph xx of the Professional person Misconduct, O. Reg. 856/93 enacted under the Medicine Human activity, 1991, Due south.O. 1991, C.xxx (hereinafter, Professional Misconduct Regulation), although see the "Charging for Missed or Cancelled Appointments" section of this policy for more information.

^9. Department ane(i) paragraph 23.2 of the Professional Misconduct Regulation.

^x. For case, while telemedicine is an uninsured service, the government has agreed to remunerate physicians providing telemedicine via the Ontario Telemedicine Network. Similarly, the Ontario Fertility Programme remunerates physicians for some fertility services that are uninsured services.

^11. This includes only is not limited to the Higher'southward Medical Records and Third Political party Reports policies also as, the Health Insurance Act, the Professional Misconduct Regulation, and the CFMA, 2004.

^12. It is an act of professional misconduct to charge a fee that is excessive in relation to the services provided (Encounter Section 1(1) paragraph 21 of the Professional Misconduct Regulation).

^13. The Canadian Medical Association Code of Ethics #sixteen states that "In determining professional fees to patients for non-insured services, consider both the nature of the service provided and the ability of the patient to pay, and be prepared to hash out the fee with the patient."

^14. For example, a representative from an insurance visitor or a lawyer. For more data see the College's 3rd Party Reports policy.

^15. Department one(1) paragraph 22 of the Professional Misconduct Regulation.

^16. Department 1(i) paragraph twenty of the Professional Misconduct Regulation.

^17. This would include any fees charged for missed or cancelled appointments and fees that are charged to patients who have chosen to pay a block fee, but where the fees for some services are merely reduced equally a result.

^18. It is an act of professional person misconduct to neglect to provide an itemized invoice when asked (See section 1(ane) paragraph 24 of the Professional Misconduct Regulation).

^19. Information technology is an human activity of professional misconduct to make a misrepresentation respecting a remedy, handling or device or to make a claim respecting the utility of a remedy, treatment, device or procedure other than a claim which can be supported by reasonable professional opinion (Department 1(1) paragraphs 13 and 14 of the Professional Misconduct Regulation).

^20. Section 17(1) of the CFMA, 2004.

^21. See sections 17(1) and 16(d) of Full general Regulation, Role Four, Conflicts of Involvement, O. Reg. 114/94 enacted nether the Medicine Act, 1991, South.O. 1991, C.xxx.

^22. This may include physicians or their role staff contacting patients or hiring a third political party (i.eastward., collection agency) to assist in the procedure.

^23. This includes, for instance, the Personal Health Data Protection Act, 2004, S.O. 2004, c.3, Sched. A.

^24. Although section i(1) paragraph 23 of the Professional Misconduct Regulation lists "charging a block fee" equally an act of professional person misconduct, physicians are able to charge a block fee as this provision has been struck down past the courts in Szmuilowicz v. Ontario (Minister of Health), 1995 CanLII 10676 (ON SC) and is therefore not in issue.

^25. See the "Constituent and Common Elements of Insured Services" of the Schedule of Benefits, read in conjunction with section 37.ane (1) of R.R.O 1990, Reg. 552 Full general, enacted under the Wellness Insurance Act and Section x of the CFMA, 2004.

^26. Department 18(2) of the CFMA, 2004.

^27. Section 18(2) of the CFMA, 2004. Come across every bit well the College'southward Ending the Physician-Patient Human relationship and Accepting New Patients policies.

^28. For example, physicians can directly patients to the College's website or refer patients to the College's Public Informational Service (1-800-268-7096 ext. 603).

Source: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Uninsured-Services-Billing-and-Block-Fees

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