COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO P O L I C Y S TAT E M E N T # 3 1 0

Block Fees and Uninsured Services

APPROVED BY COUNCIL: REVIEWED AND UPDATED: PUBLICATION DATE: KEY WORDS: RELATED TOPICS: LEGISLATIVE REFERENCES: September 2000 November 2004, May 2010

Dialogue, Issue 2, 2010

Block fees; Uninsured services; Annual fees; Ontario Health Insurance Plan (OHIP); Professional misconduct Practice Guide; Medical Records; Ending the Physician-Patient Relationship; Accepting New Patients

Health Insurance Act, R.S.O. 1990, c. H.6; Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5; Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991)
Guide to Third Party and other Uninsured Services, Ontario Medical Association

REFERENCE MATERIALS: OTHER REFERENCES: COLLEGE CONTACT:

Dialogue, March/April 2006 New policy sets out block fee expectations
Public and Physician Advisory Service

Block Fees and Uninsured Services

INTRODUCTION
Patients may need some services that are not covered by the Ontario Health Insurance Plan (OHIP). Examples of these types of uninsured services include sick notes for work; copy and transfer of medical records; and prescription rells over the phone. Physicians are entitled to charge patients for uninsured services, which take physician time and resources. To make it more economical and/or convenient for those patients who may use many uninsured services, physicians may offer patients a block fee. The purpose of this policy is to set out the Colleges expectations of physicians who charge for uninsured services and/or offer a block fee.
Uninsured services:

Services provided by a physician to a patient which are not paid for by OHIP. This includes services provided to uninsured individuals.
Block fee:

A block fee4 is a at fee charged for a predetermined set of uninsured services. This at fee may also be called an annual fee (if it covers a period of 12 months).5

POLICY
A physician cannot charge patients for insured services, including the constituent elements of these services.6 However, a physician may charge a reasonable fee7 for the performance of an uninsured service.

PRINCIPLES
1. The physician-patient relationship is based on trust, and as such, the patient must be condent the physician will put the needs of the patient rst. 2. Good communication is a fundamental component of a trusting physician-patient relationship. 3. Patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship, or pose a barrier to accessing health care services.

1) Charging for Uninsured Services: Individually or Block Fee

If physicians charge patients for uninsured services, they must make a list of fees8 available to the patient. This list must be available regardless of whether the fee will be paid on an individual per service basis, or in the context of a block fee.
a) Reasonable Fees

DEFINITIONS
Insured services:

Services listed in the Health Insurance Act and the Schedule of Benets for which physicians will be compensated by OHIP,1 provided that the service is being rendered to an insured person.2 In many cases, an insured service is comprised of several constituent elements. Examples of constituent elements of an insured service include the referral of a patient to a specialist and the administrative processing for a new patient being accepted into a practice.3

Physicians must ensure that the fees charged for uninsured services are reasonable, whether the fee is charge individually for services, as provided, or is included as part of a block fee.9 If physicians charge a block fee, the amount charged must be reasonable in relation to the services offered under the block fee. Physicians should refer to the Ontario Medical Association document, Physicians Guide to Third-Party & Other Uninsured Services, for the recommended schedule of fees. Physicians are obligated to let patients know if 10 they will be charging more than this guide.
b) Limitations to Charging Fees11

Physicians should be aware that there are several services

6. A physician may charge patients for services if the physician opted out of OHIP prior to December 23, 2004; the patient is not eligible for OHIP insurance; or if the services are not insured services which would otherwise be paid for by OHIP. 7. For more information, refer to the Reasonable Fees section of the policy. 8. Physicians cannot charge an administration fee if patients elect to pay per service. 9. Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 21. 10. Physicians should be aware that it is professional misconduct to charge a fee for a service that exceeds the fee set out in the then current schedule of fees published by the Ontario Medical Association without informing the patient, before the service is performed, of the excess amount that will be charged, under section 22 of Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991). 11. Physicians should also be aware of other activities relating to fees which may constitute acts of professional misconduct under Ontario Regulation 856/93.

1. 2. 3.

4.

5.

The services paid for by OHIP are set out in Section 11.2 of the Health Insurance Act and the Schedule of Benefits. An insured person is entitled to insured services under the Health Insurance Act and its regulations. For a complete list of the common and specific elements of insured services that are considered to be constituent elements of the insured medical services, see the preamble of the Ontario Ministry of Health and Long-Term Care, Schedule of Benefits: Physician Services under the Health Insurance Act. Although section 1 (1) 23 of Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), lists charging a block fee as an act of professional misconduct, physicians are able to charge a block fee as this provision has been declared ultra vires and is of no force and effect. This does not prevent physicians from calling a flat fee charge for a predetermined set of uninsured services by another name (i.e., Patient Supplemental Plan), provided that it is not misleading.

CPSO POLICY STATEMENT BLOCK FEES AND UNINSURED SERVICES

listed in regulation12 that a physician may not charge patients for. These include: Services not performed (but a physician may charge for the cancellation of an appointment less than twentyfour hours before the appointment time, or in psychotherapy practice, in accordance with any reasonable written agreement with the patient).13 An undertaking not to charge for a service or class of services.14 An undertaking to be available to provide services to a patient.15

Provide patients with a copy of this policy or the appended information sheet for patients.18 Answer any questions patients may have about the physicians billing policy and about any charges they do not understand. Obtain written conrmation if the block fee option is chosen and maintain it as part of the patients medical record.19 Patients must be given the opportunity to rescind the decision to pay block fees within a week of their original decision (in which case they would be required to pay for services individually, as provided).
b) Patient Access to Care

2) Offering a Block Fee

Physicians may offer patients the option of paying for uninsured services by way of a block fee. A block fee may be a more convenient and/or economical way for physicians to administer fees for uninsured services, and for patients to pay for these services. Physicians offering a block fee must ensure the fee covers a period of not less than three months and not more than 12 months.
a) Patient Choice

Patient decisions regarding payment for uninsured services must not affect their ability to access health care services. Physicians must not: Require that patients pay a block fee before accessing an insured service. Offer to or treat patients preferentially because they agree to pay a block fee. Terminate a patient20 or refuse to accept a new patient21 because that individual chooses not to pay a block fee.22

Physicians who charge for uninsured services are not required to offer the option of paying by block fee. However, those physicians who offer the option of payment for uninsured services through a block fee must also provide patients with the alternative of paying for each service individually at the time that it is provided. To ensure patients are fully informed of their payment options for uninsured services, physicians who offer a block fee must: Offer a block fee in writing,16 indicating the services that are covered by the block fee and providing examples of those (if any) that are not, along with a list of fees17 that will be charged individually for each service should the patient not select the block fee option.
12. 13. 14. 15. 16. Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991). Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 20 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s.1(1) 23.1 Ontario Regulation 856/93, as amended (made under the Medicine Act, 1991), s. 1(1) 23.2. This can include e-communication; however, physicians must provide information to patients by other means (i.e., mailed letter) if their patient(s) do not have access to the internet. Physicians should be aware of the inherent risks in using e-communication with patients and refer to relevant privacy legislation, policies and guidelines for further direction. 17. Physicians cannot charge an administration fee if patients elect to pay per service. 18. If the physician does not provide the patient with a copy of this policy or information sheet, then he or she must inform patients how they may obtain a copy. Physicians can refer their patients to the CPSO for further information about the CPSO policy.

3) Use of Third Party Companies

Physicians may use third party companies to assist them to administer a block fee or payment for uninsured services. Any communication to patients should identify the fact that a third party was involved. Third parties who are asked to administer block fees or payment for uninsured services are acting on the physicians behalf. Physicians are responsible for ensuring these companies adhere to the same standards required of physicians.

19. For more specific guidance on medical records requirements, refer to the Colleges Medical Records policy. 20. For more specific guidance on ending the physician-patient relationship, refer to the Colleges Ending the Physician-Patient Relationship policy. 21. For more specific guidance on accepting new patients, refer to the Colleges Accepting New Patients policy. 22. Commitment to the Future of Medicare Act, 2004, S.O. 2004, c.5, s. 18 (2).

CPSO POLICY STATEMENT BLOCK FEES AND UNINSURED SERVICES

Patient Information Sheet

APPENDIX: BLOCK FEES AND UNINSURED SERVICES
Insured services are services which are paid by the Ontario Health Insurance Plan (OHIP). A physician cannot charge patients for insured services. Uninsured services are not covered by OHIP. These include things like sick notes for work, missed appointments, copy and transfer of medical records, and prescription refills over the phone. A physician may charge a patient a reasonable fee for providing an uninsured service. Many physicians charge fees according to the Physicians Guide to Third-Party & Other Uninsured Services, published by the Ontario Medical Association.

There are two ways a physician can charge patients: (1) for each service, or (2) a block fee. A block fee is a flat fee that physicians can charge for a number of uninsured services. Patients who use a lot of uninsured services may find this a more economical and/or convenient option.
If a physician offers you a block fee, they must do the following:

Let you know if a third party will administer the block fee on their behalf. Give you a week to change your mind about paying a block fee (in which case you would be required to pay for services, as provided).
Physicians cannot:

Allow you to choose whether you would like to pay a block fee, or pay for each service individually at the time that it is provided (pay-per-service). Provide you with the block fee option in writing, including a list of services which would be covered by the fee and examples of those services (if any) that are not covered. Provide you with a list of fees that will be charged individually for each service if you do not select the block fee option. Provide you with a copy of the CPSO policy or this information sheet (or tell you where to get a copy). Get your written conrmation if you select the block fee option. Ensure the block fee covers a period of not less than three months and not more than 12 months. Ensure the amounts charged are reasonable in relation to the services offered. Ensure you agree to the fee before receiving the uninsured service.

Refuse to provide an insured service because you choose not to pay a block fee. Stop treating you because you decide not to pay a block fee. Refuse to accept you as a new patient because you choose not to pay a block fee. Promise or provide preferential services to you if you pay a block fee. Charge an administration fee if you decide to pay-perservice. Charge a fee for services not performed, undertaking not to charge for a service, or being available to provide an insured service.

For more information, please refer to the CPSO Block Fees and Uninsured Services policy on our website at: www.cpso.on.ca under Policies.

COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO

80 COLLEGE STREET, TORONTO, ONTARIO M5G 2E2