What Medical School Didn't Teach You About OHIP And Medicare Billing
In our conversations with 100+ new physicians and practices in 2023, the reality became all too clear: new Ontario physicians lose an average of $35,000 - $70,000+ in their first year due to preventable billing errors.
The core reason: They have so much to absorb and adjust to that they can’t give billing the attention it deserves and they don’t know the landscape.
The costs: In AFP models, the APF partnership pays the physician a percentage of their average billings, but the average is calculated as an average of their first year practicing… so every dollar missed is an additional several cents missed for the rest of their time in the AFP. If you’re not in an AFP, the costs are still a multiple of what you’re missing because you lose the money AND the opportunity that the dollar had to make even more in interest or debt reduction.
The Business Reality No One Discusses
Medical school prepares you to heal patients. It doesn't prepare you to run a profitable medical practice. The harsh truth? You're now an entrepreneur, not just a clinician and professional.
Top 5 Billing Mistakes Costing You Revenue
1. Incorrect Code Selection
Most new physicians underutilize high-value codes:
Complex care codes often go unclaimed
Missed opportunity: $5,000-$8,000 annually
Solution: Regular coding education (like our free OHIP billing webinar on the 30th) and periodic 3rd party reviews (most billing companies will review your claims and give you feedback for free)
2. Time Management Failures
Using OHIP's standard $250/hour rate, consider these losses:
1 hour weekly on inefficient billing = potentially a $13,000 annual opportunity cost ($250 X 52 weeks a year)
Delayed submissions reduce reimbursement speed and risk stale dating
Implement strict documentation protocols immediately
3. Inadequate Record-Keeping
Audit-proof documentation requires:
Precise, contemporaneous notes that back up the claims and codes used, and the nuances needed. For example, an anesthesia doctor noting the position of the patient, the time of the encounter starting and comorbidities. Each can make a difference to their compensation.
Clear rationale for procedures
Complete patient context documentation
4. Missing Premium Opportunities
Overlooked billing premiums are missed too often, are nuanced and include but aren’t limited to:
After-hours care rates
Complex patient management codes
Comprehensive care coordination fees
5. Improper Modifier Usage
Common modifier errors result in:
3-5% revenue reduction
Increased audit risk
Potential compliance challenges
Building Your Billing Foundation
Essential First-Year Strategies
Invest in billing software compatible with OHIP (many EMR companies have this, and there are others available as stand-alone solutions)
Schedule monthly billing reviews
Consider professional billing support to ensure you maximize return
Track your metrics religiously
Financial Planning Baseline
Expect 20-30% revenue variability in first year
Maintain 3-6 months operating expenses in reserve, and save them as quickly as possible
Understand your breakeven point clearly by looking at your bank and credit card statements over a 3 month period, adding all the costs up, and dividing by 3. You’ll need that number PLUS an average of 40% to compensate for taxes, professional fees and other expenses. With that 40% premium added to the average, you have a “break even” number you can live with.
Action Plan: Your First 90 Days
Month 1
Comprehensive coding training and hire professional support
Software and system setup
Initial billing process documentation, understanding and practice with oversight
Month 2
First comprehensive billing audit
Process refinement
Revenue trend analysis and consider projection
Month 3
Performance benchmark establishment
Identify optimization opportunities
Preliminary tax and financial planning
Q: How much can a new physician expect to earn in their first year of OHIP billing?
A: First-year earnings vary widely, typically ranging from $180,000 to $250,000 depending on specialty, with family physicians averaging around $225,000. However, inefficient billing can reduce this by up to $35,000.
Q: What are the most common OHIP billing mistakes for new physicians?
A: Top billing mistakes include incorrect code selection, missed premium opportunities, poor time management, inadequate record-keeping, and improper modifier usage. These errors can result in 3-5% revenue loss annually.
Q: Do medical residents need billing training before starting practice?
A: Yes. Over 90% of physicians lack formal business training. Proactive billing education can prevent first-year revenue losses and establish strong professional practices.
Q: How often should new physicians audit their OHIP billing?
A: Quarterly comprehensive audits help identify systemic errors and optimize revenue capture strategies, and are frequent enough that there is minimal risk of stale dated claim values being high.
Q: What billing software works best for new Ontario physicians?
A: Recommend EMR-integrated solutions like Oscar, ACCURO By QHR, and Practice Solutions. Ensure compatibility with OHIP submission requirements and real-time error checking. Confirm with any provider you consider to ensure you can bill inside the solution.
Q: How much time should physicians allocate to billing activities?
A: Budget 4-6 hours monthly for efficient billing management. At OHIP's $250/hour rate, optimize this time to minimize opportunity costs and remember to track the time to count as a deduction against income. An option is to hire a billing optimization service like Physicians First Claims Concierge, delegate the claims, focus on the charting and spend one hour a month on a coaching call to learn and improve billing practice.
Q: Can medical residents bill OHIP while in training?
A: Residents can bill under specific supervised conditions. Confirm exact requirements with your training program and the Ontario Medical Association.
Q: What documentation is crucial for OHIP billing compliance?
A: Comprehensive patient notes including:
Detailed visit context
Diagnostic reasoning
Treatment plan
Procedure justification
Q: How can new physicians minimize billing errors?
A: Strategies include:
Regular coding education
Using professional billing services
Investing in robust EMR systems
Conducting monthly self-audits
Q: What are the top high-value OHIP billing codes for new physicians?
A: Highest value codes include:
Complex care management
Comprehensive annual health assessments
After-hours emergency care
Chronic disease management
Q: How do OHIP billing rates compare to other provincial systems?
A: Ontario's rates are competitive but complex. Rates vary by specialty and service type, with frequent updates requiring ongoing education.
Q: What resources exist for new physician billing education?
A: Key resources:
Ontario Medical Association billing guides
OHIP provider documentation
Professional billing workshops
Online certification programs
Q: How can physicians track their billing performance?
A: Use metrics like:
Monthly revenue
Claim acceptance rates
Average time to reimbursement
Revenue per patient encounter
Q: What penalties exist for incorrect OHIP billing?
A: Potential consequences include:
Claim rejections
Revenue recovery
Potential audit
Compliance investigations
Q: Can international medical graduates bill OHIP differently?
A: IMGs must complete additional certification and comply with specific registration requirements before full OHIP billing privileges.
Q: How quickly can new physicians expect OHIP reimbursement?
A: Typical reimbursement timeline is 4-6 weeks, with electronic submissions processed faster than paper claims.
Q: What technology helps optimize OHIP billing?
A: Recommended technologies:
Cloud-based EMR systems
Automated coding assistants
Billing optimization software
Real-time claim tracking platforms
Q: How do physicians handle billing for complex patient cases?
A: Utilize specific modifiers, provide comprehensive documentation, and consider consultation codes for intricate medical scenarios.
Q: What ongoing education is recommended for OHIP billing?
A: Annual coding updates, quarterly workshops, professional association memberships, and continuous learning platforms.
Q: How can physicians protect themselves from billing audits?
A: Maintain meticulous records, use standardized documentation, conduct regular self-audits, and stay updated on OHIP regulations.
