What specialists who work most days of the year should know about OHIP billing review

Some specialists work most days of the year because the work requires it. Hospitalists cover weeks of consecutive service. Intensivists and anaesthesiologists take call. Long-term care physicians round on fixed days whatever the calendar says. Their billing looks different from a specialist who runs a clinic three days a week.

That difference now draws attention. In late October 2026 the Ministry of Health began writing to physicians whose billing patterns are higher than peers with similar practices. One version of the letter flags a high number of days worked in a single year. Our explainer covers what the high volume billings letter says and what the OMA has advised.

This post covers how OHIP reviews physician billing, what a reviewer looks for, and what it means for a specialist whose calendar is full.

OHIP pays first and checks later

OHIP pays claims on what the Ministry calls an honour system. Each claim passes automated checks, then pays. The Ministry states plainly that not every payment rule can be computerized, so a paid claim does not mean every requirement was met.¹

The checking happens afterwards, through post-payment review. Most physicians only learn how that process works when a letter arrives.

How the Ministry picks physicians to look at

According to the Ministry's own summary of the audit process, most potential billing concerns come from tips or complaints: from the public, from people working in health care, or from other physicians. Others come from regulators such as the CPSO, or from Ministry staff noticing changes in billing volume or in the use of a fee code.¹

The Auditor General's December 2025 report criticised that reliance on tips. It found more than 100 physicians a year billing all 365 or 366 days, and at least 59 a year billing more than 24 hours of service in a single day.² Letters keyed to days worked are a response to that kind of finding.

The Ministry has not published the thresholds it uses, and the OMA is asking how physicians were selected. Any figure you see quoted for a cutoff is a guess.

The stages of a review

The Ministry describes three stages.¹ Most reviews do not reach the last one, and a settlement can happen at any point.

Initial action. The Ministry's Provider Audit Unit reviews the physician's claims history. It then decides to take no action, to send billing education, to ask the physician to review their own records and correct any payment error, or to open a full audit. The high volume billings letters sit at this stage. They ask physicians to review their billing and documentation, and they request no records.

Full audit. If the Ministry identifies what it calls a potentially substantial billing concern, it writes to the physician and requests medical records. It asks for a reply within two weeks confirming the records will be provided. Collecting records typically takes three to six months. The Ministry then shares its findings, and the physician can respond in writing. The General Manager of OHIP forms an opinion, typically one to three months later. The Ministry says the whole process generally takes less than 12 months.

Board hearing. If the General Manager concludes that claims were inappropriate and no settlement is reached, the matter can be referred to the Health Services Appeal and Review Board. Absent a settlement or voluntary repayment, the Ministry can only recover money if the Board orders it. The Board can order repayment for a period of up to 24 months that began no more than five years before the review was requested.

You can retain legal counsel at any stage. If you receive a request for records, contact the CMPA and get legal advice before sending anything. Our guide to how OHIP audits work covers the process in more detail.

What a reviewer looks for

The Health Insurance Act lists the findings that allow the General Manager to refer a matter to the Board. Among them: the service was not rendered, it was not rendered in accordance with the Act and regulations, there is no record of it, its nature was misrepresented, or it was not medically necessary.¹

For a specialist who works most days of the year, that usually comes down to whether the record matches the calendar. Three things matter most.

The days add up. A claim dated to a day you were away, or to a weekend you did not cover, adds a day you did not work. Service dates keyed wrongly, or claims dated to the day they were entered, distort the day count the Ministry sees.

Timed services carry their times. The Ministry's billing brief on time-based services requires the start and stop times of direct contact in the medical record. A total such as "45 minutes" does not meet the standard. Time claimed for one service cannot overlap with time spent on any other billable service.³

The physician delivered the service. The same brief states that services must be personally rendered by the physician, with defined exceptions for supervised trainees. The October letters single this out. We cover it in what OHIP means by personally rendered services.

Your billing number carries the claims

The Ministry's October letters state that physicians are responsible for every claim under their billing number, "regardless of who submits the claims on their behalf."

Most specialists who work this many days have someone else submitting their claims: a billing agent, a hospital billing office or a clinic team. Whoever keys the claim, the claim is yours. If you have never looked at what is being submitted under your number, now is a sensible time to look.

Post-payment review and manual review are different things

Physicians often confuse two separate processes. Post-payment review is everything above: the Ministry looking back at claims already paid. Manual review happens before payment, when a claim is routed to a Ministry assessor instead of paying automatically. The OMA reported in March 2026 that complex surgical claims routed to manual review often wait six to nine months, and that about 1.16 million claims a year are rejected.⁴

A high-volume practice can be caught by both: claims held before payment, and paid claims questioned afterwards.

Knowing what your record shows

A letter asking you to review your billing is easier to read when you already know what your billing shows. We review the last six months of a specialist's claims: how the service dates line up with the days you worked, how timed services are recorded, and what was rejected and never resubmitted along the way. The review is free, and you see what we find before you decide anything.

We do not respond to the Ministry for physicians, and we do not give legal advice. For a letter, start with the OMA. For a request for records, start with the CMPA.

References

1. Ontario Ministry of Health, Summary of physician FFS post-payment audit process, March 2021.
2. Office of the Auditor General of Ontario, Oversight of physician billing, December 2025.
3. Ontario Ministry of Health and OMA Education and Prevention Committee, Requirements for time-based services, billing brief, updated June 2025.
4. Ontario Medical Association, Doctors going unpaid as OHIP flags 1M-plus claims a year, March 2026.

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If you work most days of the year and want to know what your billing shows, start with a free review of your last six months.