Uninsured Services: Billing and Block Fees – Update: Policy Approved

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    Stakeholder feedback

    View the feedback we received to our online survey

    View the comments posted to our online discussion page

    Our Process

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    The College’s Uninsured Services: Billing and Block Fees policy received final approval from Council on November 30, 2017, and is now an official policy of the College of Physicians and Surgeons of Ontario.

    We would like to thank all those who submitted their feedback and contributed to this policy review. While not every comment or suggested edit was incorporated into the final policy, all comments were carefully considered in light of current practice issues, the values and duties of medical professionalism, and the College’s mandate to protect the public.

    Below is a brief summary of the policy review process, including an overview of the feedback received and revisions undertaken.



    Who we heard from

    • 118 submissions were received in response to this consultation.
    • Feedback was primarily submitted by physicians, but we also heard from members of the public, other health-care professionals, and a few organizations including Canadian Doctors for Medicare, FAIR Association, Ontario Medical Association, Ontario Medical Association Sections on Sport & Exercise Medicine, and Ontario Medical Association Section on Respiratory Disease.
    View the feedback: Survey reportWritten Comments

    What we heard

    Other important considerations

    • Generally speaking, feedback was polarized. Many respondents, including both physicians and physician organizations, were supportive of the draft policy and recommended taking a more firm stance on key issues. In contrast, some physicians felt that the draft policy would compel them to work for free.
    • Notwithstanding this, a strong majority of respondents felt that the draft policy was clearly written and easy to understand and agreed with new expectations pertaining to, for example, educating patients about uninsured services, billing for missed appointments, and how block fees are offered.
    • Substantive and constructive feedback was provided on a number of issues. The follow are representative of the comments received:
        • The draft policy should more clearly allow for office staff to assist in educating and informing patients about fees for uninsured services;
        • Concerns were raised about physicians’ ability to assess their patients’ ability to pay a fee and with the embarrassment that patients may feel if they must self-identify as being in need; and
        • Recommendations that the draft policy more comprehensively address issues that arise when insured services are bundled with uninsured services or when uninsured services are offered as an alternative to insured services.
    • In addition to the feedback, we considered a wide range of other information while developing the final policy. This included:
        • Policies and guidelines of other organizations, including other the Canadian Medical Association, the Ontario Medical Association, and other Canadian medical regulators.
        • A review of relevant legislation.
        • A broad literature review, that included a review of patient experiences when being offered a block fee or when asked to pay for uninsured services, and potential billing issues such as extra-billing and payment for preferential access to care.

    How we responded to your feedback

    • The revised policy retains the key content and central principles of the previous policy, but a number of revisions and additions were made in response to the feedback obtained and research undertaken.
    • Some specific examples of revisions undertaken are set out below.
    Policy decision Rationale
    • The policy now includes an Executive Summary outlining key topics and expectations.
    • Feedback from internal and external stakeholders indicated that the length and complexity of College policies can sometimes make utilizing and navigating them difficult.
    • The policy includes new language recognizing that patients paying for uninsured services are reliant on the honesty and integrity of their physician.
    • Payment for uninsured services is not subject to the same external monitoring as insured services. As such, patients paying privately are particularly reliant on their physicians to ensure their needs and interests are put first.
    • The policy now notes that physicians are prohibited from charging patients for insured services and from charging any amount in excess of what the provincial health insurance plan has or will pay (e.g., extra-billing, user fees).
    • In response to reports of potentially egregious billing practices, this content was added to remind physicians of their legal obligations under the Canada Health Act and the Commitment to the Future of Medicare Act, 2004.
    • The policy now requires physicians whose practice structure leads to faster access to insured services when they are bundled with uninsrued services to ensure that doing so complies with the legal prohibition on charging or accepting payment in exchange for preferential access to insured services.
    • The Commitment to the Future of Medicare Act, 2004 prohibits charging or accepting payment in exchange for preferential access to care.

    The final policy

    • The Uninsured Services: Billing and Block Fees policy received final approval from Council on November 30, 2017, and is now an official policy of the College of Physicians and Surgeons of Ontario.

    Read the Final Policy

    • A Patient Information Sheet has also been developed to help patients understand what they are entitled to and what to expect when their doctor charges them for uninsured services or offers them the option of paying a block fee.

     Key messages of the final policy:

    1)    The expectations of the policy apply broadly to the provision and billing of all uninsured services.

    2)    When charging for uninsured services, physicians must ensure that their fees are reasonable and must, except in the cases of emergencies, communicate their fees in advance of providing the service.

    3)    Physicians must consider the patients’ ability to pay fees and consider whether it would be appropriate to reduce, waive, or allow for flexibility on compassionate grounds.

    4)    Physicians who intend to charge patients for missed or cancelled appointments without required notice must have a system in place to allow patients to cancel. They must also ensure that patients are informed of the cancellation policy in advance, and have been available at the time of the appointment.

    5)    Physicians must be clear and impartial when proposing uninsured services as an alternative or adjunct to insured services. If physicians structure their practice in a manner that leads to faster access to insured services when combined with uninsured services, they must ensure that doing so complies with the legal prohibitions against granting preferential access to insured services.

    6)    Physicians offering patients a block fee must do so in writing, satisfying a number of requirements including: indicating that a block fee is optional, inviting and helping patients assess whether a block fee is in their best interest, and refraining from using language that is or could be perceived as coercive or suggestive that without payment care will suffer.