Ontario Health Insurance Plan

INFOBulletin

Hospitalist and Internal Medicine Premiums-Interim Payment

An interim retroactive payment for the Hospitalist Premium and Internal Medicine Office Assessment Premium has been made.


To: All Providers
Category: Physician Services
Written by: Claims Services Branch, Ontario Health Insurance Plan Division
Date issued: January 20, 2021
Bulletin Number: 210106


Background

The Ministry of Health (ministry) and the Ontario Medical Association (OMA) have been working together to implement physician compensation increases in accordance with the 2019 Kaplan Board of Arbitration Award.

This will be achieved through amendments to physician compensation under contracts and to regulations under the Health Insurance Act, including the Schedule of Benefits for Physician Services (Schedule).

Please see INFOBulletin 201106 titled ‘Release 5 Changes and K229A Eligibility Incident Resolution‘ for all Release 5 Changes. This includes the new Hospitalist and Internal Medicine Premiums which were effective April 1, 2020 with an implementation date November 1, 2020.

Hospitalist Premium

Effective November 1, 2020, the Hospitalist Premium and Internal Medicine Office Assessment Premium were implemented. For details on eligibility and payment criteria, refer to INFOBulletin 201106 and to the General Preamble of the Schedule of Benefits for Physician Services (the Schedule).

Physicians with specialty designations 00 (General and Family Practice) or 13 (Internal Medicine) who are practicing as a Hospitalist and submitting claims for qualifying services at the levels specified in the Schedule in the previous fiscal year (April 1-March 31) are eligible for the Hospitalist Premium of 17% on the qualifying services except for E082A. For fee for service claims, the 17% premium is applied to the fee approved amount, and for shadow billed claims (paid at $0.00 with an I2 explanatory code), the premium is paid according to the physician group’s agreement for shadow billed claims.

For eligible claims submitted on or after November 1, 2020, the Hospitalist Premium payments will be made monthly and will be reported on the Remittance Advice (RA) under the Premium Payments section. The first payment appeared on the December 2020 RA.

An interim retroactive payment for the Hospitalist Premium for claims previously submitted with service dates for the period of April 1, 2020 to October 31, 2020 will be paid on the January 2021 RA and will report under the Accounting Transaction portion of the RA. The final retroactive payment for eligible services between April 1, 2020 and October 31, 2020 is tentatively scheduled for the summer of 2021 and will be communicated in a future INFOBulletin.

Internal Medicine Office Assessment Premium

Physicians who submitted claims solely with the Internal Medicine specialty designation (13) in the previous fiscal year (April 1-March 31) are eligible for a premium of 12% on the qualifying services. For fee for service claims, the 12% premium is applied to the fee approved amount, and for shadow billed claims (paid at $0.00 with an I2 explanatory code), the premium is paid according to the physician group’s agreement for shadow billed claims.

For eligible claims submitted from November 1, 2020 onwards, the Internal Medicine Office Assessment Premium payments will be made monthly and will be reported on the RA under Premium Payments section. The first payment appeared on the December RA.

An interim retroactive payment for the Internal Medicine Office Assessment Premium for claims previously submitted with service dates for the period of April 1, 2020 to October 31, 2020 will be paid on the January 2021 RA and will report under the Accounting Transaction portion of the RA. The final retroactive payment for eligible services between April 1, 2020 and October 31, 2020 is tentatively scheduled for the summer of 2021 and will be communicated in a future INFOBulletin.

Please note, the interim retroactive payment for the Internal Medicine Office Assessment Premium does not include virtual care services (K083A) rendered between April 1, 2020 to October 31, 2020. Also, the Internal Medicine Office Premium Payment will not automatically calculate on K083A submissions. As per INFOBulletin 4764, eligible Internal Medicine physicians may add the value of the premium to their calculation of eligible K083A claims. For further information regarding previously submitted K083A claims missing the eligible premium, please see INFOBulletin 201003.

Keywords/Tags

Kaplan; Hospitalist Premium; Internal Medicine Office Assessment Premium; Year 4; Release 5

Contact Information

Do you have questions about this INFOBulletin? Send an email to the Service Support Contact Centre or call 1-800-262-6524.

General Information

The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit Publications Ontario. Physicians without access to the Internet can contact ServiceOntario at 1-800-668-9938.

This bulletin is a general summary provided for information purposes only. Physicians are directed to review the Health Insurance Act, Regulation 552, and the schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/laws. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.

Find INFOBulletins online on the Ministry of Health website.

For More Information

Call ServiceOntario, Infoline at:
1–866–532–3161 (Toll–free)
In Toronto, (416) 314–5518
TTY 1–800–387–5559.
In Toronto, TTY (416)327–4282
Hours of operation: Monday to Friday, 8:30am – 5:00pm

 
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