Doctor Works Unpaid to Care for Dying Baby, Sparks Billing Debate

A doctor in the Toronto area, Dr. Jane Healey, recently made headlines after providing ten days of unpaid care for a newborn suffering from a terminal genetic condition. When the Ontario Health Insurance Plan (OHIP) rejected the claim for her services, Healey faced a difficult decision: either forgo her payment or ask the grieving parents to navigate a bureaucratic process at Service Ontario. Ultimately, she chose compassion over compensation, stating, “That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you,” as reported by CBC Toronto.

Healey’s experience highlights a broader issue within Ontario’s healthcare system, where OHIP billing complications have become a significant source of concern for physicians. The Ontario Medical Association (OMA) has been vocal about the need for reforms as negotiations for a new compensation agreement with the provincial government continue. An arbitrator recently urged both parties to address these challenges promptly.

Health Minister Sylvia Jones‘s spokesperson, Ema Popovic, emphasized that over 99 percent of OHIP claims are processed automatically, which reflects the system’s efficiency. However, with over 200 million claims processed annually, approximately 1.16 million are rejected each year. Doctors often do not receive payment for treating uninsured patients, which raises questions about the sustainability of their practices.

Complex Claims Create Barriers for Physicians

Dr. Healey, who also serves as the OMA’s section chair of pediatrics, noted that many unresolved OHIP billings arise from complex medical procedures, such as surgeries involving multiple physicians. According to the ministry, two-thirds of claims requiring manual review fall into the category of “complex surgical claims.” This administrative hurdle can deter doctors from undertaking innovative procedures, as they may feel burdened by the need to prove the validity of their work. OMA president Dr. Zainab Abdurrahman stated, “They’re thinking, ‘wow, I’m just going to have to be fighting to prove that I already did this work.’”

Popovic defended the province’s manual review process as appropriate for complex claims, noting that more than 95 percent are resolved within 30 days. In cases where doctors disagree with the outcome, they have the option to appeal.

The OMA has been advocating for the reinstatement of a good-faith payment system, which would allow physicians to bill for patients who do not possess a valid health card, including newborns and critically ill individuals lacking insurance.

Calls for an Ombudsman and Administrative Reforms

In light of ongoing issues, the OMA is also proposing the establishment of an OHIP ombudsman office staffed with clinical experts to facilitate the review of complex claims. Dr. Abdurrahman remarked, “Having people who are reviewing operating room notes or various physicians’ technical notes who don’t have clinical expertise, that isn’t matching up. So that’s causing issues.”

Currently, physicians are responsible for the final review of nuanced cases, according to Popovic. She affirmed that the ministry is working to streamline administrative processes for doctors and is committed to collaborating with the OMA to modernize the billing system for greater efficiency.

Popovic expressed disappointment that the OMA is focusing on the less than one percent of claims requiring manual review instead of acknowledging the progress made in supporting physicians. If an agreement is not reached by the start of 2024, both parties can return to arbitration, according to the arbitration award documentation.

Dr. Healey’s situation serves as a poignant reminder of the challenges faced by healthcare professionals in Ontario. The ongoing discussions about OHIP billing and compensation may ultimately shape the future of patient care and physician satisfaction in the province.