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Billing Review

review for midterm

When does OHIP coverage become effective? After 3 months
What are the exceptions to the 3 month waiting period for OHIP coverage? Newborn babies born in Ontario. Protected persons (refugees). People from another province who move directly into a long term care facility
Why do we submit claims to the MOH? The Doctor gets paid, and therefore we get paid.
How much time do we have to submit claims? 6 months after the date of service
What date must claims be submitted by each month? Claims must be submitted by the 18th of each month
When will you receive verification of payment? Verification of payment will be received on the 15th of the following month
What are 2 major problems MOH has in operating OHIP? 1. OHIP card fraud 2. Inappropriate billing by hospitals and physician offices
What steps can be taken to prevent fraud? 1. Ask patient to present health card at every visit 2. scan health card to verify 3. check expiry date of all health cards 4. if they do not have health card, ask them to sign a health number release form
What do you do when someone presents with a fraudulent card? Take possession of the fraudulent card and report it to MOH
What are the 4 types of information required on a claim? 1. Provider information 2. Patient information 3. Service information 4. Additional information
Provider/Physician Information 12 digit number. First 4 digits represent the clinic or group. Next 6 digits represent the individual provider number. Last 2 digits represent the area of practice.
Patient Information Health number. Date of birth. Version code. First and last name.
Service Information Service code. Fee. Number of services. date the service was provided. Diagnoses codes
Additional Information Referring physician number. Facility number (has 4 digits). In patient admission date.
What are the billing types? (HCP) Health Care Plan, (WCB) Worker's Compensation Board, (RMB) reciprocal medical billing, (Patient pays) Direct, Third Party Billing
WCB Worker's compensation billing, WSIB (Worker's Safety Insurance Board), Bill visit through OHIP indicating it is WCB, all WCB forms are paid by faxing the form to WSIB.
RMB Reciprocal medical billing, used to bill for services rendered by a physician to insured patient from another province
Direct Billing Patient pays for services rendered that are not covered by OHIP. Non-canadian citizens; patients considered "out of country" must carry travel insurance or be billed directly.
3rd Party Billing Billing insurance company, billing lawyers, billing interim federal health (IFH), billing UHIP.
Block fees Physicians choose to ask patients to subscribe to a monthly or yearly fee to cover some services (eg. sick notes, phone calls, Rx renewals)
How many digits are in an MOH code? 5 digits. Alpha prefix, 3-digit numeric, alpha suffix.
What 3 codes are required for OHIP billings? Assessment code. Service code. Diagnostic code.
Codes for Physicals K017 - annual health - 2-15 years old. K130 - periodic health visit - 16-17 years old. K131 - periodic health visit - 18-64 years old K132 - periodic health visit - 65+
Technical Fees Person administering test. Alpha suffix B.
Professional Fees Analyze test results. Alpha suffix C.
Who initiates special health visits? The patient and/or their representative initiates the special health visit
What are special health visits? Dr. visiting a long-term care facility, patient's home, hospital, emergency, etc.
MOH Age Definition Newborn: birth - and including, 28 days Infant: 29 days - less than 2 years Child: 2 years - and including, 15 years old Adolescent: 16 & 17 years old Adult: 18+
Visit/Procedure Codes General assessment: everything, for a diagnostic reason. Physicals: based on age Intermediate assessment: check more than one system of the body Minor assessment: check one body system Prenatal (major, minor)
K codes are used for: counselling, physicals, psychotherapy, education of a patient's condition and/or treatment
What is billed in "units" (30 min. intervals)? Counselling, psychotherapy.
What is a basic fee? when a procedure is the sole reason for the patient's visit
What is a primary visit? Visit with the patient within 2 weeks of discharge from the hospital
What is a monthly management fee? A fee billed by the MRP for routine medical care for one calendar month. Ministry prefers when this is billed on the last working day (mon-fri) of the month.