The Ultimate Guide to Medical Billing Systems for Ontario Physicians

Ontario’s healthcare system relies on efficient medical billing processes to ensure timely reimbursements and maintain practice viability. With over 29,410 physicians in the province generating $11.61 billion in annual payments, adopting optimized billing software is critical. This guide analyzes the OHIP billing ecosystem and provides evidence-based recommendations for maximizing revenue capture efficiency while ensuring compliance with provincial regulations.

Overview of Ontario’s OHIP Billing Ecosystem

The OHIP Fee-for-Service Framework

Ontario physicians primarily operate under fee-for-service (FFS) or patient-enrolment payment models. In 2014/15, 62% of payments ($7.2 billion) flowed through FFS arrangements, while 29% ($3.38 billion) used patient-enrolment models. The FFS system requires precise submission of claims containing:

• Patient health card number and demographics

• Service dates and facility codes

• OHIP fee codes

• Diagnostic codes and applicable premiums

Claims must adhere to the MC EDT system specifications, which mandates GoSecure authentication and real-time eligibility checks.

Billing Cycle Dynamics

Ontario’s monthly billing cycle includes:

• 18th of each month: Soft cutoff for claim submissions at 5:00 PM EST, but Physicians First typically finds the actual cutoff is typically the last Thursday of the month, around noon.

• 4th–7th of the following month: Remittance advice distribution (when OHIP sends the Ontario Physicians and billing groups the breakdown of what revenues we being paid, what codes are being rejected, and why etc.

• just before or on the 15th business day: Payment issuance for approved claims

Missing these deadlines can delay payments by up to 60 days.

Critical Features of Medical Billing Software

Automated Error Reduction

Services like our Clarity Dashboard Solution and other tech solutions like ClinicAid and Dr.Bill help reduce rejections (among other errors, of course) through:

• Pre-submission audits

• Batch edit reconciliation

• Real-time MC EDT eligibility checks

These features directly target common rejection codes like AT3 and EH2.

Fee Code Management

Modern tools like Alembico EMR maintain up-to-date OHIP schedules, including:

• Base service codes like A263

• Premiums like E078

• Telehealth codes for 10+ minute consultations

Practice Management Integration

Other known billing software platforms in Ontario include (but certainly aren’t limited to):

• CabMD for automatic claim generation via scheduling

• HYPE Medical for EMR connectivity

• YES Medical for analytics and denial tracking

Leading Medical Billing Software Solutions

ClinicAid

• Built for Ontario

• MC EDT automation

• Mobile billing for locums

Dr.Bill

• RBC-discounted platform

• Group billing and denial management

• Excellent appeal automation

CabMD

• Trusted by over 5,000 physicians

• Transparent pricing

• Full integration with patient flow

Compliance and Regulatory Requirements

MC EDT Enrollment

To bill via OHIP, physicians must:

1. Get a CPSO certificate so they are licensed to practice in Ontario

2. Register with the MOH Service Support Centre

3. Set up GoSecure

4. Authorize any third-party billing agents or billing administrators

Audit Obligations

MOH regularly conducts post-payment reviews. Ensure your billing software creates audit trails to stay compliant with provincial guidelines and avoid clawbacks.

Financial and Operational Impact

Revenue Optimization

• Proper code usage can boost revenue by 15–50%

• Platforms are helpful to reduce denial rates through automated pre-audits, but few things help ensure you collect 100% of earned revenue like a platform + professional assistance

Cost Considerations

• Pricing models range from monthly SaaS fees, to perpetual licenses (i.e. one price to use the service forever) to a percentage of revenue processed

• Transparency is key—watch out for low costs or percentages with hidden service fees

Ontario’s billing environment is complex—but not insurmountable. Tools like ClinicAid, Dr.Bill, and CabMD help reduce denial rates, improve compliance, and enhance operational visibility. The right software isn't just a tool—it's a revenue strategy.

Questions and Answers

1. What is the best OHIP billing solutions in Ontario?
   There are many choices in Ontario, and the Physicians First Claims + Clarity Concierge service may be the best due to compliance, automation, their guarantee to recover more than they cost, and percentage-based pricing transparency.

2. What is MC EDT and why does it matter?
   MC EDT is Ontario’s secure claim submission system—your software must be integrated to submit OHIP claims.

3. What is GoSecure?
   GoSecure is the secure login platform for physicians submitting OHIP claims digitally.

4. Can I submit claims without billing software?
   Yes, but it’s error-prone and time-consuming. Software helps avoid rejections and speeds up payments.

5. What is A263 in OHIP billing?
   It’s the code for a general medical assessment—currently worth $77.70.

6. What’s E078 in OHIP billing?
   A premium code for chronic disease management—it adds +50% to your base fee.

7. Can I bill for telemedicine in Ontario?
   Yes—OHIP allows billing for virtual consults over 10 minutes using telehealth codes.

8. What are the common OHIP claim denial reasons?
   Invalid card numbers (EH2), missing referrals (AT3), and incorrect fee codes.

9. How often are OHIP remittances issued?
   Once a month—payments are typically deposited around the 15th business day.

10. What happens if I miss the OHIP billing deadline?
    Claims are delayed by 30–60 days and might be excluded from the current cycle.

11. Is mobile billing possible for locums?
    Yes—platforms like Dr.Bill and ClinicAid offer mobile-optimized portals.

12. Does billing software help with audits?
    Yes—systems like YES Medical and Alembico log detailed audit trails.

13. What is the cost of OHIP billing software?
    Monthly rates range from $30–$100+. Some platforms offer discounts through banks or associations.

14. What is the benefit of group billing features?
    They allow clinics with multiple providers to manage billing under one system.

15. Do I need an EMR to use billing software?
    No—but integration with your EMR significantly boosts efficiency.

16. Can software automatically verify OHIP eligibility?
    Yes—via real-time MC EDT integrations.

17. What is batch billing?
    Sending multiple claims at once, often automated and timed via your software.

18. Can I appeal denied claims via software?
    Dr.Bill and others include built-in tools to auto-generate appeals.

19. What reports can billing software generate?
    Revenue by provider, top rejections, denial rates, and service volume summaries.

20. Is cloud-based software secure?
    Yes—reputable platforms meet HIPAA and PHIPA standards with encryption and access control.