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What Are the Billing Procedures Under Medicare?

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What Are the Billing Procedures Under Medicare? What are the billing procedures under medicare? PATRICIA TESKEY Medical care legislation, coming specifically to the difference be- ernment about how much the pa- under provincial jurisdiction in tween what the government plan al- tient was billed directly for the serv- Canada, varies from province to lowed and the individual practi- ice so plan officials have complete province. Physicians planning to re- tioner chose to charge for a given information as to what insured res- locate in another province, there- service'. But Bill 16 also terminated idents are actually paying for med- fore, face the challenge of inter- this "balance billing" provision. ical care. preting that province's medical care The law states that in areas of Any physician-patient disputes system, the benefits allowed for the province where laboratory, ra- over the amount charged are ar- services and the individual physi- diologic or qlectrodiagnostic facil- bitrated by an assessment commit- cian's options for billing patients. ities don't receive a license, the pa- tee set up by legislation and admin- Of course, the provincial medical tient pays for the service directly istered by the College of Physicians associations or societies as well as and can't recoup the money from and Surgeons of Alberta. individual colleagues will offer ex- the plan; however, when it comes cellent advice when it comes time to to practical application, there are Saskatchewan choose whether to be "opted in" hardly any unlicensed facilities in Government body: Medical Care (participating) or "opted out" (non- the province. Insurance Commission (MCIC) participating); but to make the ini- Legislation: Medical Care Insurance tial research easier for the physician Alberta Act on the move, we have put together a Government Saskatchewan physicians don't face province-by-province summary of body: Alberta Health an ".all in" or "all out" choice. The billing options in Canada. Care Insurance Plan (part of the Department of Hospitals and Med- practitioner can choose to bill one ical Care) patient directly, while billing the British Columbia Legislation: Alberta Health Care plan on behalf of a second patient. Government body: The Medical Insurance Act Normal practice is for a physician Services Commission (MSC) to consult with each patient individ- Legislation: Bill 16 In Alberta there are no non-par- ually about payment method. ticipating or "opted out" physicians. The law stipulates that the phy- Physicians in British Columbia have The terms "opted in" and "opted sician must give a patient who is two billing options only: a parti- out" don't apply in this province billed directly a detailed statement cipating physician bills the MSC because the law doesn't require of account enabling the patient to plan and receives payment from the practitioners to make an all-or- obtain MCIC reimbursement before MSC; a non-participating physician nothing choice. If the physician the physician demands payment. bills the patient directly and the wants to charge the patient more All billings to patients are legally patient receives reimbursement than the plan benefit, he or she termed "Mode III" under the Sas- from the MSC plan. simply is free to do so; but the law katoon Agreement (1962) and are The passing of Bill 16 in the BC does stipulate that the physician referred to as "direct billing." legislature. in Spring 1981 removed must inform the patient of the fee Unlike their Alberta colleagues, any provision for limited extra bill- before the service is given. Saskatchewan physicians aren't al- ing. "Balance billing", therefore, lowed to "split the bill" between Prior to Bill 16, "balance billing" means "splitting the bill": the phy- the patient and the MSC (i.e. set a in BC was a mechanism for com- sician sets the fee, then sends out fee of $110, then charge the plan promise in the case of failed nego- two statements - one to the plan $100 and the patient $10). Rather, tiations between the BC Medical for the benefit amount, and the if the physician wants to charge Association and the MSC, and the other to the patient for the differ- more than the plan benefit, he or term "balance billing" referred ence. she must bill the patient for the. full The Alberta Health Care Insur- amount. The patient, in turn, is re- Patricia Teskey is a freelance writer ance Act also stipulates that the imbursed by the plan for the bene- living in Ottawa. practitioner must inform the gov- fit amount. 1280 CMA JOURNAL/DECEMBER 1, 1981/VOL. 125 Onice a physician has decided to government. These agencies are al- ered to the plan on behalf of the "opt in" for a patient's service, he most archaic because most physi- patient (at present, most choose to or she cannot choose to "opt out" cians see sending a bill to an agency do this) or, give the patient suffi- for subsequent treatment for the as just another step in the process, cient information about the medical same condition (i.e. bill the plan for therefore a longer wait before they services provided to enable the pa- an office consultation for a sore receive the payment. The agencies tient to recover the money from the throat, then bill the patient directly are still there, though, as an option MHSC. for a following tonsillectomy). for those who choose to use them. However, if that same patient re- Ontario appears in the physician's office a Manitoba Government bodv: Ontario Health few months later for a completely Insurance Plan (OHIP) (Ministry new service, say for influenza, the Government body: Manitoba Health of Health) patient and physician can renego- Services Commission (MHSC) Legislation: Health Insurance Act tiate the manner of payment. Legislation: Manitoba Health Serv- ices Insurance Act In Ontario, physicians must either Physicians in Saskatchewan avoid "opt in", in which case they bill the the term "extra-billing", although Manitoba physicians can decide to plan and must accept plan benefits it is often used as a political term "opt out" of the government insur- as payment in full, or "opt out" in by the media and by those against ance plan, but 'it's an "'all in" or which case they must directly bill direct billing and Mode III. "all out" option: a physician can't the patient who is then reimbursed Saskatchewan physicians have a be "opted in" for one patient and by the plan. The non-participating third choice of billing patients "opted out" for another. practitioner sends a statement of through approved nongovernment The term "balance billing" services rendered to the plan on be- agencies of which there are two: doesn't apply in Manitoba because half of the oatient. "Balance billing" Medical Services Incorporated "opted in" physicians must accept or "splitting the bill" is not per- (MSI) located in Saskatoon and plan benefits as payment in full for mitted. Group Medical Services (GMS) in their services; they are not per- "Extra billing", a term used Regina. These agencies are incor- mitted to charge or collect fees rather widely in the Ontario press porated societies with physician and from insured residents in excess of but avoided by the profession be- non-physician members and con- the benefits payable by the plan. cause of its negativity, refers to the trolled by the medical profession. If a physician decides to "opt amount a non-participating physi- They were established at the time out", his or her patients don't lose cian bills in excess of the govern- medicare was introduced in Sas- entitlement to benefits for insured ment benefit schedule. The Ontario katchewan to issue extra health services. Legislation requires a non- Medical Association recommended benefits - to collect for and insure participating physician to provide fee schedule is at present 43% physicians. However, the actual patients with reasonable notice that higher than that of the government. practice of billing through these they will be billed directly. Ontario premiums provide eligib- agencies is now limited to a very The law also stipulates that non- ility for both medical and hospital few physicians who object in prin- participating physicians must either care insurance. A non-participating ciple to receiving payment from the send a statement of services rend- physician working in a hospital can elect to bill the plan directly on a patient-to-patient basis for the patient's hospital care only (not for office treatment or consultation either before or after). If a non-participating physician bills in excess of the OMA sched- ule, the physician must advise the patient in advance of the exact amount. Quebec Government body: Regie d'assu- rance-maladie du Quebec Legislation: Loi de l'assurance ma- ladie In all other provinces it's the pro- vincial medical associations or so- cieties that negotiate fee schedules and billing options with the govern- ment; but in Quebec, it's different. ("Being different is part of our CMA JOURNAL/DECEMBER 1 1981/VOL. 125 1281 charm" explains Dr. Gerald Caron, A participating physician can bill in Nova Scotia, and at present there Quebec Medical Association exec- either the plan or the patient direct- is only one "opted out" physician utive director.) General practition- ly if he or she advises the patient in the province. ers should seek advice on these mat- in advance. The physician who bills As in Alberta, the Nova Scotian ters from the Federation des me- the plan must accept the plan bene- practitioner "splits the bill", send- decins omnipraticiens du Quebec, fit as payment in full for the serv- ing one bill to the government for and specialists should go to the ices; therefore "balance billing" or the amount of the tariff, and an- Federation des medecins specialistes "splitting the bill" are terms that other to the patient for the amount du Quebec.
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