Doctor’s Heartfelt Decision: Caring for Dying Infant Without Pay

A Toronto-area pediatrician, Dr. Jane Healey, chose to care for a critically ill newborn without compensation, highlighting ongoing issues within the Ontario Health Insurance Plan (OHIP). After the claim for the newborn was rejected, she faced a difficult decision: request payment or burden the grieving family with more bureaucracy. Ultimately, she decided against troubling the parents during their time of loss.

The infant passed away after ten days due to a genetic condition, underscoring the emotional toll on healthcare providers dealing with such fragile situations. “That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you,” Dr. Healey told CBC Toronto.

As a prominent figure within the Ontario Medical Association (OMA), Dr. Healey pointed out that she is not alone in facing these challenges. Billing complications within OHIP have become a critical issue as physicians negotiate a new compensation agreement with the provincial government. Recently, an arbitrator instructed both parties to expedite solutions to these matters.

According to a spokesperson for Health Minister Sylvia Jones, Ema Popovic, over 99 percent of claims are automatically processed. “This reflects the system’s productivity,” she stated. However, with more than 200 million claims submitted annually, approximately 1.16 million claims are rejected each year, leaving many physicians unpaid for their work with uninsured patients.

Dr. Healey explained that complex procedures, such as surgeries requiring multiple specialists, often result in unresolved OHIP billings. In fact, two-thirds of the claims sent for manual review fall into the category of “complex surgical claims.” This creates a disincentive for doctors to engage in innovative procedures, as noted by OMA president, Dr. Zainab Abdurrahman.

“They’re thinking, ‘wow, I’m just going to have to be fighting to prove that I already did this work,’” she remarked. This situation could potentially hinder advancements in medical care across the province.

In response to the complexities of the manual review process, which can take months and often involves intricate cases, the OMA has proposed the establishment of an OHIP ombudsman office staffed with clinical experts. This initiative aims to address the shortcomings in the current review system, where non-clinicians assess nuanced medical cases. Dr. Abdurrahman emphasized the need for qualified personnel to evaluate operating room notes and other technical documents.

The ministry, however, maintains that the existing manual review process is appropriate for complex claims, with more than 95 percent of cases resolved within 30 days. Doctors have the option to appeal decisions, which provides some level of recourse.

Both the province and the OMA are under pressure to reach an agreement concerning good-faith payments and the manual review process for complex claims. The OMA has advocated for the revival of a good-faith payment system, allowing healthcare providers to invoice for patients lacking valid health cards, such as newborns or critically ill individuals without insurance.

Popovic expressed disappointment that the OMA has chosen to concentrate on the minority of claims that require manual review, rather than acknowledging the progress made in supporting physicians. She indicated that the government is actively working to modernize the billing system to improve efficiency.

If an agreement cannot be achieved by the start of the new year, both parties can revert to arbitration as per the arbitration award’s stipulations. As the dialogue continues, Dr. Healey’s experience sheds light on the broader implications of OHIP billing issues, emphasizing the need for reform to support healthcare providers and ensure they are compensated for their critical work.