Some Endocrinologists Fudge the OHIP Rules

I'm a little steamed, as are some doctors I know, because of a little fudging of the OHIP rules by one particular specialty on unsuspecting patients in order to bump income. I get why they want to earn a decent amount for their time and expertise and are exasperated with the cheap-o provincial government; but I don't like the way they're going about it.

I've seen more doctors than I care to admit to; I have doctors in the family, as well as nurses; and my recent lawsuit introduced me in more detail to the ins and outs of OHIP records and medical codes than I cared to know. (Yes, insurance companies get easy access to those medical records. Fun, eh?) And so, unfortunately, I'm fairly familiar with OHIP and the kind of payments physicians receive for consultations, how they get those payments, and that procedures earn more money than simple consultations. The fees that I'm thinking of in particular are $105 for an initial consult -- which should be longer than 5 minutes as the idea is that the doctor has never met you before -- $54 per general assessment follow-up, but limited to only four per year -- and $18.50 for any and all visits thereafter for the rest of the year after the initial consult. So, as you can see, if you have a chronic illness that requires regular visits of greater frequency than every 3 months, your physician will probably lose money on you or just break even once they cycle into the $18.50 realm, for they still have to pay for all the costs of their office staff and expenses, as well as equipment maintenance, office rental, payouts to the teaching hospital if that's where they practice to help make up the income of research-only doctors, and their own time. If they need to do a procedure, then that will offset the loss on consults. But some doctors are not in the kind of specialty where procedures are done or are done rarely.

And so how do they earn a fair income? They may restrict their visits to 5 minutes or less in order to retain the same hourly rate as if they were earning the initial consult fee or even the quarterly one. (But I'd like to point out that excellent doctors won't do that; they know that in order to help their once very sick patients stay well, they need to spend the same amount of time with them for $18.50 as for $54 as for the $105.) This method is what many patients grumble about: you feel like you've been brushed by a speeding train and left spinning with your mouth
hanging open on all your unanswered questions.

However, there is another, fudgy way.

As you may know, specialists require a referral from the family physician in order to submit their bills to OHIP. No referral, no payment. Furthermore, if you don't see your specialist for over a year, even if it's one year plus one day, you will need to get another referral in order to see him or her. With that new referral, the specialist can once again charge the initial consult fee. However, there does have to be a one-year-plus lag between appointments in order to ask for another referral. And that's where it gets interesting.

I stumbled upon this interesting practice by endocrinologists (as far as I know), and only because I happen to know the rules. Apparently, a few family physicians know all about it too and aren't too impressed, but it doesn't seem like OHIP has cottoned on to it. What really pisses me off about it is that it means more work for the family physician -- like they really need it -- and wasted time for the patient. I understand that OHIP rates suck and that repeat consult fees totally ignore the reality of looking after the chronically ill, but imposing on overworked family physicians and their staff, as well as the patient, is not the solution.

Basically, if you reschedule an appointment or forget it or if your repeat appointment falls past the one-year date of your first appointment, then you will be required to get another referral -- contrary to OHIP rules. In other words, some endocrinologists assert that they get the initial consult fee once per year regardless of how often they saw you that year -- they usually see you every 4 to 6 months -- not on the fact that you haven't seen them for over a year.That way they can earn $105 instead of the $54 they're really entitled to. Interesting, no?


Mark Dowling said…
You should consider getting in touch with this MPP's office to see if he would bundle the issue with the one he's chasing:
Interesting article. It sounds to me like Wilson got bit in the butt by the change in referral rules, which I think (could be wrong) were instituted by his government. He can't possibly be suggesting that the dermatologist should see him for free, now can he?

I love one answer to his dilemma: blackmirth wrote "all you have to do to avoid $125 referral fee is find a walk-in clinic that isn't boarded-up and sit in the waiting room for three hours surrounded by squalling toddlers and people coughing and spitting-up all around you, and if the receptionist calls your name in close-enough pronunciation and in-between shrieks and coughs for you to hear it, you can go in and be asked why you are wasting the precious time of the walk-in clinic with this non-urgent concern. And go home with the flu."

That was another concern with those bogus endocrinologist referrals cause GPs got those bawling, sniffling kids in their offices too.

The block fees are a whole other issue. And it isn't just family docs charging them either. Some doctors can't keep up with the change in the phone rules (charge if patient calls, can't charge if doc calls) and charge the patient for those when shouldn't. It's a mess!

And then there was a further change in the referral rules that applied specifically to ob/gyn, who often act as the doc many women go see for an annual instead of their GP, for various reasons, which I frankly think has upped the cost to OHIP by forcing women to see the doc every single year no matter how they're doing in order to keep the ob/gyn as their doc.

Politicians often get special treatment from docs, especially cabinet members. I've heard of them even getting cancer meds that the gov't won't pay for or restrict for us ordinary joe blows. Seems like Wilson was expecting the usual preferential treatment. I have no sympathy for Wilson as he was party to this mess. But if his pain will bring common sense back to the referral rules and bring fairness to OHIP rates, then it will have been worth it.

Thanks for the link!