Medical Coding and OHIP Billing: 5 Key Differences for New Ontario Physicians

Transitioning to practice in Ontario? Understanding the Ontario Health Insurance Plan (OHIP) billing system can feel different than U.S. medical billing. This guide clarifies five key distinctions to equip new Ontario physicians with the knowledge needed for smooth financial practice management. The most important overarching theme here, which a doctor practicing in Ontario may not realize, is that there are cultural nuances reflected in our system here. For example, the Ministry of Health runs most the major medical service insurance plans in Ontario. WCB covers patients in worker-related injuries, and the stream runs parallel to the OHIP plans. OHIP will generally pay much of what is claimed and will pay by the 15th day of the month after the service was rendered… Coding is more complex than it seems and there is a lack of readily available information about coding available, making learning the art of OHIP coding very challenging.

1. OHIP Billing Code Structure and Negotiation

OHIP uses a unique fee code system detailed in the Schedule of Benefits for Physician Services. This schedule is renegotiated every four years between the Ontario Medical Association (OMA) and the Ministry of Health, as there is typically one major insurer and one body that represents physicians in the province. Each code represents a specific service and includes modifiers for provider roles (e.g., primary surgeon, assistant). Fees are pre-determined and non-negotiable.

In contrast, the U.S. employs Current Procedural Terminology (CPT) codes maintained by the American Medical Association, and Healthcare Common Procedure Coding System (HCPCS) codes for Medicare/Medicaid. While the Centers for Medicare & Medicaid Services (CMS) sets Medicare rates, private insurers often negotiate rates independently, leading to a more complex pricing structure.

2. OHIP Claim Submission Deadlines

Ontario has a strict three-month claim submission deadline from the date of service. Claims submitted after this window are considered "stale-dated" and are typically rejected (see policy). IF you are a doctor or clinic operator with stale-dated claims and a legitimate reason why these claims were left with this status, Physicians First is able to manually review and attempt to recover some of these monies on your behalf.

The U.S., specifically Medicare, allows up to a one-year submission period for clean claims, as outlined in 42 CFR § 424.44. This difference significantly impacts billing workflows and requires Ontario physicians to prioritize timely submissions.

3. Payment Models and Reimbursement

Ontario offers a mix of payment models:

• Fee-for-Service (FFS)

• Alternate Funding Plan (AFPs) that blend capitation, salaries, and incentives

• Salary, common in academic or community health settings

OHIP payments are issued monthly via direct deposit, typically 10 business days after the monthly cutoff. The cutoff is never earlier than the 18th of the month, and is typically on the last Thursday of the month.

The U.S. predominantly uses FFS, but reimbursement timelines vary:

• Medicare typically processes electronic claims within 14 days

• Private insurers may take 30+ days

4. Provider Registration and Billing Credentials

Ontario physicians require a unique six-digit OHIP billing number obtained after receiving an Independent Practice Certificate from the College of Physicians and Surgeons of Ontario (CPSO). This process involves registering practice addresses and direct deposit information with the Ministry of Health.

U.S. providers use a 10-digit National Provider Identifier (NPI), a federally issued identifier. Additional credentials, like Medicare enrollment, are needed for participation in government programs.

5. Handling Out-of-Province/Country Claims and Uninsured Services

OHIP facilitates reciprocal billing for patients from other Canadian provinces (excluding Quebec). Direct billing is required for Quebec residents and international patients, with physicians setting market rates for uninsured services. The OMA provides billing guidance for uninsured services.

In the U.S., out-of-state billing involves navigating payer-specific rules, with variations in coverage and restrictions on balance billing under the No Surprises Act.

Understanding the key differences between OHIP and U.S. medical billing is essential for new Ontario physicians. Adapting to OHIP's unique code structure, strict deadlines, and payment models ensures accurate billing, timely reimbursements, and financial stability. For further guidance, consult the OMA’s General Principles of OHIP Billing and utilize tools like the MC EDT system.