How to Minimize Your Reliance on OHIP's Manual Review Process
For Ontario specialists and internal medicine physicians, navigating the OHIP billing system can be a significant administrative challenge. While most claims are processed automatically, a subset is flagged for the Manual Review process, leading to payment delays, increased overhead, and disrupted cash flow. The key to a healthier revenue cycle isn't mastering the complex inquiry system after a claim is flagged; it's preventing the flag from being raised in the first place.
This guide focuses on prevention. We will explore the most common and complex billing errors that trigger Manual Reviews and outline the documentation and coding best practices that lead to cleaner initial submissions. By adopting these proactive strategies, you can minimize your reliance on the manual review system and ensure your practice receives timely and accurate compensation for the services you provide.
What is the most effective Physicians First strategy to reduce reliance on OHIP's Manual Review process?
The most effective strategy is a proactive, multi-faceted approach centered on submitting "clean" claims. This involves a systematic focus on accuracy and completeness before submission. Research shows that physicians often fail to bill for at least 5% of insured services due to a lack of attention to detail during the claims process individual.utoronto.ca. A proactive strategy addresses this by integrating several key Physicians First best practices: rigorous health card validation at every visit, precise diagnostic coding, correct use of Service Location Indicators (SLIs), and meticulous documentation, especially for time-based services and consultations. By building these checks into your daily workflow, you can significantly reduce the errors that lead to manual reviews and improve your first-pass claim acceptance rate.
What exactly is the OHIP Manual Review and why is it so costly for a practice?
The OHIP Manual Review is a secondary assessment mechanism used when a claim cannot be processed by the primary automated system. While about 80% of claims are processed automatically, the remaining 20%—often the most complex and high-cost ones—require manual inspection by a Ministry of Health assessor onepercentsteps.com. This process is triggered when claims have unusual billing combinations, fail automated checks, or are intentionally flagged by the provider with supporting documentation.
The financial implications are substantial. An auto-adjudicated claim costs mere pennies and is processed in minutes. In contrast, a claim undergoing manual review can cost as much as $20 to adjudicate and take days or even weeks to process onepercentsteps.com. This delay directly impacts your practice's cash flow and increases the administrative burden on your staff, who must spend valuable time preparing documentation and following up on claim status.
What are the most common billing errors that trigger a manual review?
Several recurring errors are responsible for triggering manual reviews. One of the most critical Physicians First tips is to be vigilant about these common pitfalls:
Health Card & Eligibility Issues: Submitting claims without validating the patient's health card at every visit can lead to rejections that may require further review. Real-time validation helps prevent this physiciansfirst.ca.
Incorrect Diagnostic Codes: OHIP requires specific diagnostic codes. Using vague or unspecified codes, like a general "unspecified elbow strain," is a common reason for refusal physiciansfirst.ca.
Wrong Service Location Indicators (SLI): Misclassifying the service location, such as using a Hospital In-Patient (HIP) code without a corresponding admission date, will trigger an error physiciansfirst.ca.
Missing Referring Physician Information: Consultation claims will be refused if they don't include the correct 6-digit OHIP billing number for the referring physician—not their 5-digit CPSO number individual.utoronto.ca.
How can improved documentation prevent manual reviews?
Comprehensive and contemporaneous documentation is the foundation of a clean claim. Medical records must contain specific elements to satisfy OHIP's payment requirements and avoid scrutiny. For complex services that are often reviewed, such as case conferences or surgeries, your documentation is your primary defense.
For Case Conferences: Records must clearly identify all participants, state the exact start and stop times of the discussion, and document the outcomes or decisions made. A single, shared note in the patient's chart, initialed by all participating physicians, can satisfy this requirement oma.org.
For Operative Reports: These must be detailed and specific, describing the actual procedure performed, the results, and the size, number, and location of any lesions. Using generic or "canned" reports is unacceptable and will likely trigger a review or rejection mcweb.apps.prd.cammis.medi-cal.ca.gov.
For Time-Based Services: Any service with a specific time requirement must have that time clearly supported in the medical record. This includes after-hours premiums which require precise start and end times oma.org.
Are there situations where I should intentionally flag a claim for manual review?
Yes, the manual review flag is a tool that should be used strategically in specific, legitimate clinical situations. It is not for general inquiries or correcting simple errors. According to Ministry of Health guidelines, you should use the "Claims Flagged for Manual Review" form for situations such as submitting duplicate service codes for the same date but at different times, resubmitting a claim with a requested operative report, or justifying the need for multiple surgical assistants ontario.ca. It should not be used for stale-dated claims (now three months from the date of service), general payment inquiries, or for services that require prior approval ontario.ca. Using the flag correctly demonstrates a clear understanding of OHIP processes and can streamline payment for complex but valid claims.
