The Canadian Bar Association
Health

“Uninsured Services: Billing and Block Fees Policy” approved by CPSO

Lonny Rosen
Elyse Sunshine

By Lonny Rosen and Elyse Sunshine 

“Uninsured services” are physician services not covered by the Ontario Health Insurance Plan (OHIP). These types of services include, for example, prescription refills and medical advice over the phone, providing copies of medical records, travel immunizations, elective cosmetic procedures, etc.

Following an external consultation, Council of the College of Physicians and Surgeons of Ontario (CPSO) recently approved the Uninsured Services: Billing and Block Fees policy setting out CPSO’s expectations on how physicians bill these uninsured services.

Overall, the policy retains the key content and central principles of the earlier policy, however, according to the CPSO, as a result of feedback, including input from the College’s Inquiries, Complaints and Reports Committee, a number of changes were made.

Of note, new language was added to emphasize how reliant patients are on the honesty and integrity of physicians when paying for uninsured services.

The revised policy also includes a new section, requiring physicians to be clear and impartial when proposing uninsured services as an alternative to, or in combination with, insured services. If the way physicians structure their practice results in faster access to insured services when combined with uninsured service, the physicians must ensure that doing so complies with the legal prohibition against granting preferential access to insured services.

The purpose of the revisions was to help avoid situations where confusion could arise when patients are paying for uninsured services.

Other requirements of the revised policy include:

  • Charging reasonable fees: Physicians must not charge for insured services, but they are entitled to charge for uninsured services, unless the government has otherwise agreed to remunerate them. Any fees charged, however, must be reasonable.
  • Patient’s Ability to Pay: Physicians must consider the patient’s ability to pay when charging for uninsured services, charging for missed or cancelled appointments, or when collecting outstanding balances. Physicians must consider whether it would be appropriate to reduce, waive, or allow for flexibility on compassionate grounds.
  • Communicating fees: Fees must be communicated before uninsured services are provided.
  • Block Fees: In addition to “pay per service,” physicians may charge “block fees” similar to an insurance policy. The patient pays a flat fee up front that would cover them for a set of uninsured services for a set amount of time. Block fees cannot be shorter than three months or longer than a year. Under the policy, when offering a block fee, physicians must comply with a number of requirements and offer the option in writing.

The full policy can be found here and a patient information sheet can be found here. Contact us if you have any questions about this new policy.

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