Ontario Health Insurance Plan

INFOBulletin

Physician Post-Payment Review and OHIP Education Resources

Post-payment review process and education resources for OHIP fee-for-service payments for physician services


To: Physicians
Category: Physician Services
Written by: Health Services Branch, Ontario Health Insurance Plan Division
Date issued: March 30, 2021
Bulletin Number: 210309


New Physician Post-Payment Review Process

In December 2019, the government made changes to the Health Insurance Act that will make the Ontario Health Insurance Plan (OHIP) more accountable (the Plan to Build Ontario Together Act, 2019). These changes include a new physician payment review process and are in response to recommendations made by the Office of the Auditor General of Ontario.

The physician post-payment review process as laid out in the Health Insurance Act is governed by principles that are designed to ensure procedural fairness, integrity, transparency, and accountability, as required by law. The Ministry of Health and Ontario Medical Association worked together to ensure that the legislation policies and procedures guiding the process reflect this. This new post-payment review process will only be applicable for reviews of claims submitted on or after May 1, 2021 and on a go forward basis. *

A description of the physician post payment review process is available as a new education resource on the Ministry of Health’s website: The Physician FFS Post-Payment Audit Process.

New Education Resources

The Ministry of Health and the Ontario Medical Association worked together to develop educational resources to support appropriate billing practices and make physicians aware of the related legislation and regulation. These educational resources promote accurate and appropriate payment for insured services by reducing billing errors for insured services.

Physicians are encouraged to review these educational resources as physicians are responsible for understanding and complying with the payment requirements in the Health Insurance Act and regulations to that Act including the Schedule of Benefits for Physician Services for claims submitted to OHIP using their personal OHIP billing number.

Physician education resources are available on the Ministry of Health’s new website: Resources for Physicians. The new Resources for Physicians webpages centralize billing information for physicians and contain newly organized content from the Online Resource Manual for Physicians. Updates will be made regularly on an ongoing basis as required. Physicians should check the website routinely to ensure they are aware of updates as they are made.

Keywords/Tags

Ontario Health Insurance Plan; OHIP; Fee-For-Service; Claims for Payment; Billing; Coding; Review; Audit; Payment Accountability; Resources for Physicians;

Contact Information

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

Find INFOBulletins online on the Ministry of Health website.

* with certain minor exceptions (e.g. reviews that were underway prior to the legislative changes).

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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