Starting your practice

Any physician that plans to practice in Ontario must acquire certain licences and memberships. Some of these may take up to three months to obtain, so it is important to contact organizations during your final stages of residency to get registration and information packages. These include:

• Your practice license from the College of Physicians and Surgeons of Ontario. Register for your license
• Your OMA membership. Register for your membership
• Your OHIP billing number from the Ministry of Health. Register for your billing number
• Your Canadian Medical Protective Association membership. Apply for your membership
• Royal College of Physicians and Surgeons of Canada. Specialists register with the RCPSC
• College of Family Physicians of Canada: Family physcians register with the CFPC

Optional associations you can choose to join include:

• Canadian Medical Association
• Ontario College of Family Physicians
• Local medical societies

Professional advisers

Your team of advisers will offer invaluable support with everything from creating your business plan to negotiating leases. Some of these roles include:

• Lawyers: Provide you with guidance regarding your contractual obligations, such as assisting with drafting and negotiating your contracts (group contract, staff contracts, leases, etc.) Contact OMA Legal Affairs or your lawyer for more information
• Accountants: Offer advice and support you with your business finances. This includes the financial analysis of your business plan, setting up a medical incorporation, taxation, cash flow, investments, risk management and retirement planning. Visit MD Financial Management (member-only content) or others for more
• Insurance: Provide guidance on your personal and professional insurance needs. Visit OMA Insurance for more

Ideally, select advisers who have experience working with health-care professionals. They can greatly assist in your quest for practice management proficiency and financial security.

Professional organizations

College of Physicians and Surgeons of Ontario

The CPSO is the licensing body for all physicians in Ontario and their role is to regulate the practice of medicine to protect and serve the public interest.

• All physicians in Ontario must be members of the college to practice
• The college has policies on professional obligations and responsibilities that you must adhere to as a practicing physician, such as “Medical Records Management” and “Professional Obligations and Human Rights”

Canadian Medical Protective Association

The CMPA provides medical liability protection that is required while practicing medicine. They support members when medical-legal issues arise.

Ontario Medical Association

The OMA advocates and negotiates with the provincial government on behalf of physicians.

We also have programs to support physicians, which include OMA Insurance, OntarioMD, Practice Management and the Physician Health Program.

Workplace Safety and Insurance Board

The WSIB provides medical coverage and support to help people get back to work after a work-related injury or illness. Physicians are required to communicate the appropriate information to WSIB for patients to be able to claim their benefits.

Information and Privacy Commissioner of Ontario

The IPC acts to protect information and privacy rights in Ontario. Patient information is protected by the Personal Health Information Protection Act.

Physicians who act as Health Information Custodians, regardless of practice setting, are required to track and provide the IPC with an annual report of all privacy breaches that occurred in the previous calendar year. HICs must notify patients upon occurrence when the patient’s personal health information has been stolen, lost, or disclosed without authority. HICs must also report certain types of privacy breaches directly to the IPC upon occurrence. Visit the Information and Privacy Commissioner of Ontario website for more.

Physician registration and the OHIP billing number

You must obtain an OHIP billing number to submit claims to the Ontario Health Insurance Plan for services rendered.

To apply for OHIP, you must:

• Hold a valid certification from the College of Physicians and Surgeons of Ontario
• Have an Ontario practice address
• Complete and sign the Application for OHIP Billing Number for Health Professionals form
• Provide banking information to support direct payment
• Register for medical claims electronic data transfer and health card validation services

It can take up to 15 business days to process your registration. You may bill retroactively up to three months prior to receiving the billing number but no earlier than the effective date on your certificate.

Group number

A group number is not a billing number. It is a number issued by the ministry that allows individual physicians to have their billings associated with a group.

Health-care groups can apply for a group number by completing and submitting an OHIP form.

Schedule of Benefits for physician services

The ministry makes payments for services insured by OHIP in accordance with the payment requirements listed in the Schedule of Benefits. The Schedule lists approximately 6,000 physician services and includes information and conditions for payment of insured services. Particular attention should be paid to the first section of the Schedule, the “General Preamble”, which provides detailed information about billing requirements and payment rules.

OHIP claims submissions

Method of submitting claims

All claims must be submitted through a medical claims electronic data transfer in accordance with Regulation 552, Section 38.3 of the Health Insurance Act. It will also allow you to validate health cards at the point of care. For more information on how to register, download the electronic data transfer reference manual. You should liaise with your software vendor to ensure all hardware and software conform to the specifications.

Types of claims

There are three main types of claims processed by OHIP.

1. Health-care payment: Claims for services rendered to a patient with OHIP
2. Workplace Safety and Insurance Board: Claims for services rendered to patients with OHIP coverage who have work-related injuries
3. Reciprocal medical billing: Claims for services rendered to a patient insured under another Canadian health coverage plan, excluding Quebec

Cut-off date for claims submission

The ministry operates on a monthly processing cycle. Submissions received by the 18th of the month will typically be processed for approval the following month.

Claims must contain complete, valid and accurate information in order to be processed on time. Claims requiring internal review by the ministry may have payment delays.

The ministry recommends daily or weekly submissions of claims to ensure timely adjudication of claims files and to aid in the subsequent reconciliation of rejected claims.

Billing for uninsured services

An uninsured services program can provide an opportunity to offset unpaid work. It is a method of billing and collecting for uninsured services. Learn more about billing for uninsured services. 

Where you practice also influences your professional and personal happiness. The community you choose must provide the basis for not only a thriving medical practice, but also for a contented home life for you and your family.

Professional factors to consider include:

• Demand for your specialty or sub-specialty in the community (e.g., is your practice focused on geriatric care yet most of the population demographic is young adults?)
• Access to hospital privileges, diagnostic facilities, support services and consultations. Contact hospitals in the community to check the time required to obtain hospital privileges, and availability of surgery time if this is something you want
• Growth/decline in population and demand for services
• Government incentives for locating in the community

Personal factors to consider include:

• Cost of living (housing, groceries, etc.)
• Social life
• Career opportunities for family members
• Transportation
• Schools
• Shopping
• Social and service organizations
• Recreational and cultural

Should you start your own practice, form a partnership, or join an established practice? There is no right answer to this question.

There are pros and cons to each option, so ask yourself some key questions:

• What kind of start-up costs am I comfortable with?
• Do I want to be a leader or part of a team?
• What type of personality do I feel comfortable working with?
• How much time do I want to spend on administration of my practice?
• Do I want to control my expenses or share them?
• How much control over my schedule do I want?
• If joining a practice, what is the revenue stream?

If you decide to go solo, your start-up costs will be higher, but you will be your own boss and are wholly responsible for your practice’s success — a draw to some. Start-up costs will be relatively low if you decide to form a partnership, but your business approach may be different from the other partners. If you join an established practice, your start-up costs will be minimal, you will have a smaller administrative load, but you are not your own boss.

Ultimately, consider what style of practice is best suited to help you achieve your professional and personal goals.

Where to find jobs

HealthForce Ontario is a provincial agency tasked with co-ordinating recruitment of health-care workers in Ontario. They host an online job board, share recruitment resources, and can support you in your recruitment journey. 

You can also try locum, which provides you with the opportunity to explore different practice types and locations to determine the best fit for you. Learn more about locums.

Other places to find jobs include:

• BookJane
• Facebook groups, such as Family Physician Job Opportunities - Ontario
• Word of mouth from

There are many benefits to joining a medical group practice, such as reduced administrative burden, less set-up cost and a collaborative professional environment. Here are some items to consider to ensure a successful union.

The group and its members

Questions to ask include:

• Does the group or its members have a reputation in the medical environment?
• Are you professionally and personal compatible with the group and its members?

Governance structure

Questions to ask include:

• Who makes decisions in the group and how are decisions made?
• Are operational and governance processes documented and in place?
• Are there regular physician group meetings and staff meetings with formal agendas?
• What is the goal of the group? Does it align with your professional goals?
• How are physicians added or removed from the group?
• What are your service obligations? Can you determine your own hours and on-call hours? How many hours are you required to work per week?
• What are your obligations if you go on leave or want to leave the group?

Cost, staff and medical resource-sharing

Questions to ask include:

• What is the group’s cost sharing model? The group should have this in writing
• What access do you have to support staff?
• How are shared medical resources scheduled? (e.g., shared exam rooms)
• Who “owns” the patient and patients’ medical records? This is important if you or someone leaves the group

Compensation factors

Questions to ask include:

• What is the compensation model? What about HST? Are billings split? If so, ensure it specificies which billings items are split (WSIB, OHIP, uninsured, third-party premiums, etc.)
• Does your pay include benefits, such as vacation, leave (bereavement, parental, medical) etc.?
• Are there any non-competition clauses that may inhibit you from working at another health-care facility?

The OMA strongly recommends having a written contract with the group outlining all details to ensure the expectations are consistent between all parties.

The contract should be reviewed by your legal counsel prior to signing it.

Purchasing a practice from another physician can be a good way of setting up a solo practice, without as many of the startup activities required.

Here are some things to consider to contribute to a smooth transition.

The business

Discuss the following with the outgoing physician:

• The clinic’s current agreements, such as leases, utilities and EMRs
• The plan for medical equipment/office furniture

Current employees’ contracts

Will the staff continue with you?

If the outgoing physician does not formally terminate the employment of their employees, you assume their employment under Ontario law. This can have financial ramifications for you if they later wish to terminate their employment. For example, an employee may have worked for you for one year, but 10 years with the previous physician; if you terminate, you will need to pay severance for 11 years.

Patient care

A few key considerations include:

• The patient roster: Talk to the outgoing physician about the transition of the patient roster to you, including patient notifications and patient expectations. For example, will your clinic hours be the same as the outgoing physician?
• Patients’ medical records: Who will be the owner of the medical records? How you will gain access to them, if the patient files are stored in an EMR system? You can contact the EMR administrator or OntarioMD for assistance
• Transition period: Discuss a possible transition period with the outgoing physician for a smoother transition. This could also include sharing the outgoing physicians’ expertise, such as a list of referring physicians and suppliers.

The OMA strongly recommends liaising with your professional advisers prior to signing the written contract.

Your legal counsel can provide advice on the contract. Your financial adviser can support your financial plan including financing and cash flow needs. Your insurance adviser can ensure you have arranged for sufficient professional insurance coverage.

Starting a group medical practice with other physicians is a great way to balance having control while sharing costs, responsibilities and having a collaborative working environment.

Here are a few things that could contribute to a successful partnership.

Create a group business plan

Writing the business plan together helps to align the practice vision.

Discuss the governance plan

The governance plan, should include:

• How decisions will be made and how physicians will be added and terminated from the practice, as well as voting and group meetings
• “Ownership” of the patients and patients’ medical records — this is especially important if a physician leaves or goes on leave
• How physician schedules (especially on-call hours) will be determined

Establish a financial plan

Discuss the following with your partners:

• How expenses will be shared (employees, leases, EMR, medical equipment, supplies, etc.) This is especially important if physicians will be working a different number of hours per week (e.g., full-time vs. part-time)
• The criteria for how physicians will be paid
• An OHIP group number. A group number is not a billing number, it is a number issued by the ministry that allows individual physicians to have their billings associated with a group. Health-care groups can apply for a group number by completing and submitting an OHIP group registration form.

The OMA strongly recommends your group governance be formalized into a written contract and reviewed by your legal counsel.

Create a plan

There is a saying that “if you don’t know where you’re going, any road will take you there.” In business, your plans become an invaluable road map to your future.

All plans hinge on a key question: What do you want from your career? This will determine the philosophy for your personal and professional goals. Everything that you do as a physician and as a businessperson should be rooted in that mission.

A business plan defines a business’s direction and describes how it plans to achieve its goals.

Writing a detailed business plan will clarify your goals, increase the confidence of your lenders, ensure medical partners are strategically aligned and share key information with your advisors.

Arrange financing

Work with your financial adviser to develop a realistic startup budget for your practice. Your business plan should assist you with negotiating your financing and help determine how much you need.

Ensure you have a business emergency fund for unexpected costs that may arise and ensure you have sufficient cash flow to run your clinic, especially in the first few years.

Set up your medical professional corporation

Some physicians will incorporate to reduce their taxes. Liaise with your financial adviser to determine if incorporating is financially beneficial to you.

The location of an office, the building, and the space you need now — and may want for the future — can influence the success of your medical practice. Consider the following factors:

Location

• High visibility
• Patient access (e.g., public transit)
• Proximity to patients
• Proximity to diagnostic services and other medical facilities (e.g., hospital)
• Proximity to your home

Building

• Rent per square foot
• Cost of leasehold improvements
• Space is zoned for commercial use and follows building codes (e.g., emergency exits, fire exits)
• Condition and maintenance of building
• Special equipment requirements (e.g., backup generators for fridges, air ventilator)
• Patient accessibility (e.g., wheelchair accessible, elevators, wheelchair bathrooms). Read the accessibility requirements for health-care providers
• Parking

Space

• How much usable space you require
• The space allows for physician public health guidelines (e.g., sinks in exam rooms)
• Expansion potential (e.g., room for potential partners or other services)

When renovating or moving to new clinical offices, you must be aware of current municipal regulations for premises as well as standards from Infection Prevention and Control Canada.

This includes specifications for exam and waiting rooms, furniture, medical device reprocessing and storage areas, medication room and hand hygiene facilities, among others. Incorporating good infection prevention and control measures at the start improves patient and staff safety.

Read the medical facility planning guide and the patient experience guide for more. 

Your lease

Relocation costs can be substantial. As such, ensure the space meets your needs. It is always better to have more space than you think you presently need, as many practices grow over time.

Before approaching the landlord, speak to other tenants of the building, get references and prepare a written summary of your requirements.

Ask the landlord to provide preliminary space planning services to show how the available space could look incorporating your requirements. Have your interior designer/construction consultant review the landlord’s proposal and prices. Determine the actual cost of leasehold improvements before you decide on how to finance them.

The lease documents prepared by the landlord should include all aspects of the offer to lease. For example, it should include termination conditions, renewable conditions, leasehold renovations, building maintenance (elevators, snow removal etc.), parking maintenance, utilities (HVAC maintenance, etc.), a force majeure clause and how the rent is calculated (gross, net, double net, triple net, percentage). It is critical that all details are in writing and incorporated into the lease contract.

Legislation for commercial leases is different than residential leases; your lease represents a large financial liability, so it is imperative to have your lawyer review the lease to ensure it contains all relevant information and negotiate any amendments required.

Staffing the clinic

Delegating tasks to others allows you to concentrate on patient care. As such, hiring staff who have the skills to support you are critical to the success of your practice.

To figure out what staff you need, start by analyzing the areas where you could best use support: What tasks can you delegate? How important are they? How much responsibility are you prepared to delegate?

Many jobs in a physician’s office require a combination of skills, so defining the skills that will best satisfy the needs of the practice will help you determine the right staff for your practice.

Read the CPSO’s guidelines on the delegation of controlled acts.

Hiring the best candidates

Once you have decided on your staffing needs, use a systemic process to select the right candidate. A typical process is as follows:

• Create a job description
• Post the job
• Interview and evaluate candidates
• Determine compensation
• Check references
• Offer employment to your chosen candidate

Determining compensation

Compensation, which includes salary and benefits, will be the most expensive component of your overhead costs; therefore, it is advisable you seek legal and financial advice.

Salaries are determined by several factors, including position responsibilities and location.

A quick online search of “salaries for medical office staff in (specify your geographical area)” will provide you with some resources on current salaries.

You can also speak with colleagues in your practice location and/or recruitment agencies.

Offer letter and employment contract

Once you have chosen a candidate, prepare an offer of employment letter. The letter should outline the salary, pay cycle (weekly, biweekly or monthly), the start date, work hours, job title, copy of the job description, probation period and employee benefits (e.g., vacation entitlement, sick days, health insurance).

It is prudent to review the offer letter and employment contract with your legal adviser or OMA Legal Services. The OMA recommends you have written contracts with all employees. Contracts should be signed prior to the first date of employment.

Onboarding

Before your new employee starts:

• Set up payroll, taxes, employment insurance and benefits for your employee
• Give the employee a tour of facility, introduce them to other staff and give them the tools required for their job (e.g., computer, phone)
• Train your staff in your business processes (phone etiquette), work-place policies (e.g., patient confidentiality), and safety standards (e.g., WHIMIS)
• Train your staff on delegated tasks (billing, patient filing)

Managing staff

Set up regular meetings to discuss the employee’s performance, training, and satisfaction.

Foster a safe and respectful work environment. Happy staff will cost you less in the long run (better job performance, lower staff turnover) and will support the success of your clinic.

Continue to train your staff in skills that will improve your practice (e.g., patient de-escalation, billing).

Assessing staff performance

An important management tool is regular performance appraisals (e.g., annually, semi-annually). These appraisals must be based on the employee’s performance compared directly to the job description.

The job description may change over time to meet the needs of the office (with the agreement of the employee).

Termination

Terminating an employee is sometimes necessary, but never easy. The Employment Standards Act defines the termination requirements that you must follow in Ontario. The rules are complex, so it is important to review with your legal adviser before proceeding.

For more information, read the OMA’s HR guide for physicians.

To put your business plan into action, you will need to create operational processes and policies for your medical practice. This may seem time-consuming, but it will help your practice run smoothly, reduce future problems and minimize administrative/business tasks.

Some systems you may need to set up and create processes for include:

• Patient appointment scheduling
• Medical records
• Accounting (includes billing, accounts receivables, account payable procedures, financial reporting)
• Uninsured services program/costing

Your office manual should include:

• Staff policies (e.g., employee conduct, leaves)
• Patient policies (e.g., patient code of conduct)
• Job processes (e.g., telephone etiquette)
• Workflow processes (e.g., who is responsible for tasks, and when and how often tasks should be completed. For example, the receptionist checks office  supplies the first week of each month)

You will need to train staff on business procedures prior to opening.

You will also need to create commonly used forms (e.g., patient intake forms, appointment cards) and obtain or create commonly used patient educational materials (e.g., diabetes care).

Continuous planning

Running a business is not static. From the day you open to the day you close, continuously seek ways to improve your practice processes. Your staff can assist you with improving the practice, so ask for their input. 

Watch the webinar on optimizing your practice efficiency.

Find other health-care providers in the community

It is important to connect with other health-care providers your patients may use prior to opening (e.g., pharmacists, specialists/family physicians, diagnostic facilities, social worker). Some ways to do this include:

• Using the OMA Practice Announcement Service (member-only content)
• Searching the CPSO physician’s database for specialist/family physicians in your community
• Connecting with health-care providers close to your clinic

You cannot have a successful practice without patients. The College of Physicians and Surgeons states physicians must employ a first-come, first-serve approach in accepting patients into their practice. Read the CPSO policy on accepting new patients.

Some ways to get patients include:

• HealthCare Connect: A provincial website to assist patients finding a primary care physician. Ensure you are registered on their website
• EMR e-referrals: Add your name to EMR e-referral systems, such as Ocean eReferral Network
• Web presence: Many potential patients will search online for physicians. Create a user-friendly website and/or social media presence to reach potential patients. Create a Google business listing for your practice. A web designer can assist you with setting up your website
• Referrals: Ask for referrals from other local health-care providers, such as pharmacists or physicians closing their practice in your community
• Word-of-mouth from current patients: Delivering quality service to your current patients will encourage the promotion of your practice to their networks
• Advertise: Be visible — have signs in your practice window, mail out flyers/brochures, take out an ad in a local newspaper and/or local community boards. A graphic designer can assist you in creating promotional materials. Note that your promotional materials must follow CPSO’s policy on advertising and social media

Communication

Effective communication is a critical aspect of a physician-patient relationship. It aids in diagnosing and managing your patients. Some ways to build a strong relationship with patients include:

• Be clear about your practice policies (e.g., frequent no-shows, not allowing abusive/threatening language to be used)
• Show respect and genuine care to your patients, including listening without judgment to their concerns
• Take into consideration your patient’s living circumstances when discussing test and treatment options
• Ensure the patient understands what you said by being specific, explaining in non-medical terms and asking the patient to confirm their interpretation of what you said

Conduct

The patient-physician relationship is governed by CPSO’s professional standards. These standards include:

• The physician’s behaviour in a professional environment
• Confidentiality of patient information and what to do if there is a breach. Read the Personal Health Information Protection Act and visit the Information and Privacy Commissioner of Ontario website for more
• Terminating a patient, who exhibits inappropriate behaviour, including abusive or threatening language. Read the policy on ending the physician-patient relationship 

As you start your career, it is important to build a practice that also ensures your well-being.

Some solutions may include:

• Establishing a schedule that allows for self-care basics, such as rest, nutrition, exercise and social support
• Establishing work-life balance through flexible work arrangements, such as virtual visits
• Creating a positive work environment at your workplace
• Finding a support system
• Continuing to learn
• Streamlining tasks to be as efficient as possible from the start of your career
• Connecting with OntarioMD to make digital health tools a seamless part of your workflow
• Being mindful of your patient size

Signs of burnout

It is important to recognize and act at the first signs of physician burnout. Common signs include:

• Feelings of alienation from work-related activities
• Headaches, stomach aches or intestinal issues
• Emotional exhaustion
• Having difficulty doing daily tasks at work or at home

If you are feeling burned out, the OMA’s Physician Health Program anonymously supports physicians, residents, medical students and their loved ones with their mental health difficulties, including substance use disorders. The PHP matches callers to community services. It is not a crisis service.

Other support networks in Ontario include:

• Practising Well, an informal space to support the care you give patients in a way that also considers your well-being
• Physician Facebook groups
• The OMA physician burnout toolkit
• Burnout 101: Signs and Strategies by the Canadian Medical Association