Doctor Cares for Dying Baby Without Pay, Highlights Billing Issues

A Toronto-area doctor, Dr. Jane Healey, recently revealed that she spent ten days caring for a newborn baby who was dying from a genetic condition without receiving any payment. The situation arose when the Ontario Health Insurance Plan (OHIP) rejected her claim for the infant’s care, leaving Healey with a difficult decision: either ask the grieving family to navigate the bureaucratic process at Service Ontario or provide care without compensation. Ultimately, she chose not to burden the family during such a painful time.

Dr. Healey shared her experience with CBC Toronto, emphasizing the emotional toll of unpaid work in the medical field. “That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you,” she explained. Her situation is not unique; OHIP billing complications have become a major concern for physicians in Ontario as they negotiate new compensation agreements with the provincial government.

Billing Complications Affecting Physicians

In September 2023, an arbitrator directed the Ontario Medical Association (OMA) and the provincial government to expedite efforts to resolve ongoing issues related to OHIP claims. Although over 99 percent of claims are processed automatically, this still leaves approximately 1.16 million claims rejected annually due to various complications. According to Ema Popovic, a spokesperson for Health Minister Sylvia Jones, this rejection rate reflects a productive system, but it raises concerns for healthcare providers.

Dr. Healey, also the OMA’s section chair of pediatrics, noted that many claims are not resolved due to the complexity of certain procedures. For example, surgeries involving multiple specialties or intricate processes often lead to billing disputes. The OMA president, Dr. Zainab Abdurrahman, highlighted that two-thirds of claims undergoing manual review are categorized as “complex surgical claims.” This situation may dissuade physicians from pursuing innovative treatments, as they face additional hurdles to demonstrate the work they have completed.

Popovic defended the province’s manual review process, asserting that it is appropriate for complex cases and that over 95 percent of these claims are resolved within 30 days. Physicians, however, have expressed concerns about the burden of such reviews and the potential impact on patient care.

Push for Changes in the System

The OMA is advocating for the revival of a good-faith payment system, which would allow doctors to invoice for patients lacking valid health cards, such as newborns and critically ill individuals without insurance. This measure could alleviate some of the financial pressures on healthcare providers working in challenging circumstances.

Additionally, the OMA proposed the establishment of an OHIP ombudsman office staffed with clinical experts to review complex cases. Dr. Abdurrahman criticized the current system, stating that having non-clinical staff review technical notes from operating rooms can exacerbate existing issues.

The Ontario government has indicated its commitment to modernizing the billing process and reducing administrative burdens for physicians. Popovic expressed disappointment that the OMA is focusing on the less than one percent of claims requiring manual review rather than acknowledging the progress made in supporting medical professionals.

As negotiations continue, both the OMA and the Ontario government face a deadline. If a resolution is not reached by the beginning of 2024, the parties may return to arbitration, potentially prolonging the uncertainty surrounding OHIP billing and its impact on patient care.