Billing education resources

The OMA and the government are committed to providing educational resources to physicians and office staff that promote accurate and appropriate payment for medical services and reduce claims payment errors. Educational resources are also available to assist physician awareness and understanding of the physician payment review process.

The Ministry of Health (MOH) and the OMA have jointly established the Education and Prevention Committee (EPC). The EPC's primary goal is to educate physicians about submitting OHIP claims that accurately reflect the services provided, and that are in compliance with the law. The Post Payment Accountability Steering Committee tasked the EPC to develop new billing education resources.

Physician fee-for-service post-payment audit process PDF icon

This guide explains the Ministry of Health’s audit process so physicians know what to expect if their claims are reviewed.

Assessments and consultations PDF icon

This guide helps identify assessment and consultation requirements, applicable limits, common billing errors, and the correct fee codes.

How to get help with billing questions PDF icon

This guide provides information on how physicians can get help with billing
questions. 

Special visit premiums PDF icon

This guide explains the three components of special visit premiums and when a visit is eligible.

Requirements for time-based services

An overview of some OHIP insured physician services that are only eligible for payment if they have been performed for a certain period of time (“time-based services”).

Understanding the Schedule of Benefits PDF icon

This module introduces the Schedule of Benefits and how to choose appropriate fee codes, with practical examples.

Ministry of Health and Ontario Medical Association

Contact us

Members are encouraged to reach out to the OMA if they require further information or clarification, and to contact the CMPA if they require representation and assistance in responding to a post-payment audit.

info@oma.org

Claims Adjudication subcommittee

While not part of post-payment accountability, as part of the work with the government in developing policies and procedures guiding the audit process, the OMA insisted on the need to look at pre-payment issues as well.

To that end, the MOH and the OMA agreed to establish the Claims Adjudication Sub-Committee (CASC) as a permanent committee to deal with pre-payment issues, as well as helping to reduce administrative burden for physicians.

The MOH and the OMA agree to continue to make every reasonable effort to ensure a timely and consistent process for adjudication of all in-province OHIP physician claims for payment. To that end, the CASC has been established with representation from both the MOH and the OMA, with the objectives of reviewing and making recommendations around:

  • The claims submission process
  • The automated Medical Claims Payment System (MCPS), such as the OHIP system “Medical Rules” and error/explanatory codes; and
  • The claims adjudication process, such as manual reviews and remittance advice inquiries (RAIs)