Physician Services Agreement – Frequently Asked Questions

On March 28, 2022, the Ontario Medical Association and the Ontario Ministry of Health announced that members decisively ratified a new three-year Physician Services Agreement. As a result, there have been several changes that have taken effect.

We know it might be overwhelming and time consuming to understand all of the changes. We want to help you leverage our platform to help alleviate the stress of keeping up with these changes and ensure you are maximizing your revenue potential and opportunities

We have compiled a list of the most frequently asked questions about the Physician Services Agreement that we have been hearing from our doctors.

The post is broken down into seven sections:

  1. After Hours Requirements
  2. FHO Formation
  3. Compensation Increases
  4. FFS Hard Cap
  5. Preventive Care
  6. Virtual Care
  7. General

After Hours Requirements

What does the Ministry mean when they say that you cannot have overlap between the after-hours blocks?

Your FHO group cannot have an overlap of after-hours blocks during your weekend coverage. For example, if two weekend blocks are required for the group and a physician is scheduled for Saturday from 9am to 12pm, then the other physician cannot be scheduled between 9am to 12pm on Saturday. They can be scheduled after 12pm.

Please note that this rule does not apply to weeknights.

Can I bill the new weekend billing code?

The new weekend code will not be released until July 1. The new weekend code will allow you to bill for scheduled and unscheduled patient visits if the physician has three scheduled visits per block.

When the new weekend code is released, we will share an update in our newsletter. Subscribe here to ensure you get the latest updates right in your inbox.

Will the A888 code still be available to use on weekends when the new Q code for after hours is available?

A888 will remain billable and qualifies only for a block of unscheduled visits. The A888 is only billed when it is on an urgent, ER equivalent, unscheduled basis.

The new Q code is to be billed when scheduled patients are also seen. Please note that you will need at least three scheduled visits to qualify for the new Q code.

What is the requirement for after hours being virtual vs. in person?

There is no requirement. Virtual care can be conducted during after hours; however, patients must be able to see the physician in-person during after hours if necessary.

If my FHO has 11 physicians, with four  of them providing hospital services, how many blocks per week do we need to provide?

To be exempted, your group will require six physicians or more provide the exempted services i.e., more than 50% of your group. Since there are only four physicians providing hospital services, no exemption will apply to your group. As per the new PSA, your group will be required to have eight blocks in total per week with six during the weekdays and two during the weekend.

For more information on the after-hour block requirements, view our quick reference guide here.

We have two doctors working at LTC and one working in a hospital. Can we exempt these three from our group of 10?

Yes, if you are meeting the criteria for hospital and LTC work. The details can be found on page 80 in the agreement.

The remaining group members will be required to provide coverage for the exempted physicians. The exemption does not mean that the required after-hours shifts will be lowered until more than 50% of the group provide outside services.

For exemptions – what exactly does the LTC non rostered pt >10 pts per week mean since all LTC pts done by the FHO physicians are rostered?

The Ministry will provide the exemption if the LTC work is over and above your FHO practice. When LTC patients are rostered, it is technically care you are providing to your patient base, not others within your community.

FHO Formation

Will existing FHO’s have to share patient access?

No, shared EMRs are required for new FHO groups only.

Can I stay in a CCM model until I can transition to a FHO?

Yes. You can continue staying on CCM until you find a FHO or a FHG to join.

Do we know the RIO score of the area where we practice?

Yes – you can find what your RIO score is here. You just need to input in your postal code and your RIO score will generate.

Is the 5 km rule for joining an existing FHO a radius or a driving distance? And can the 5 km rule apply to any location in the FHO or only the main site (in previously existing FHOs with multiple locations)?

The 5km rule is a radius. However, it is calculated based on driving route for patient accessibility between clinics. It would be 5km from the closest FHO established clinic, not necessarily the lead’s location.

Do all the doctors in FHO have to be on the same EMR from day one, or is there a grace period where they can share two EMRs?

They must be on a shared EMR on the date of their FHO’s commencement.

Is there a grace period when a new doctor joins an existing FHO regarding access and outside use or will their negative access impact group from day one?

From the Ministry’s end, the impact is from day one., However, the FHO group’s governance agreement will dictate whether there is a grace period for any negative payback mechanism.

What is the minimum number of rostered patients required if a patient sees a doctor at a walk-in clinic?

Walk-in doctors should not be enrolling the patient as there is no continuity of care.

When switching from a FHG to FHO, do they need sign a departure notice?

When forming a new FHO, no departure noticed is required. However, when joining an existing FHO, a departure notice is required. The end date will be one day prior to FHO commencement.

What happens to rosters larger than 2400?

No group will be able to form if they have more than an average of 2400 per physician. Please note that this requirement is based on the average across the whole group and not at the individual physician level.

Compensation Increases

Are the compensation increases only for billing codes? Are increases coming for capitation payments for rostered patients as well?

Increases will be for both the billing codes and capitation payments.

What is required to update the fee schedule in the EMR?

The Ministry has announced that physicians must ensure that their billing software is updated to reflect the new FSC values for any services rendered on or after April 1, 2022. The updated Fee Schedule Master can be found on the Ministry of Health website.

To get your EMR updated with the new Schedule of Benefits, we recommend you contact your vendor or contact us at info@doctorcare.ca for help.

FFS Hard Cap

Are GP consultation codes (eg A005, A911, etc) in the FFS hard cap?

No. Those are out-of-basket codes and therefore do not impact the hard cap. Only in-basket services, rendered on non-enrolled patients count towards the FFS hard-cap.

Preventive Care

When I submit a claim, I use just one diagnosis even though I often discuss several issues. Should I add all diagnoses now that the capitation will include comorbidities?

You can only put on DX code per visit code, and it is usually the most prominent one for the reason of the visit associated with that fee code.

Do we still need to bill tracking codes for preventive bonuses for this year?

Yes, you can still track preventive care this year and bill it for next year for this fiscal year.

Will we get preventive care bonus next year?

Yes, you will get your preventive care bonus for the 2022-2023 fiscal year payment.

Regarding the preventive care bonus change for patient comorbidities, does that mean current preventive care bonuses are going away for cervical cancer/breast cancer/colorectal cancer?

Yes, the changes will take effect in April 2023. Only childhood immunizations and flu vaccines will be considered preventive care.

As of April 2023, the preventive care bonus will be used for capitation rate. Does that bill for percentage met?

Doctors will bill for the 2022/223 preventive bonuses next year between April 1 to September 18, 2023, for the previous fiscal. However, starting April 2023, no future preventive care will count towards a bonus.

How will the Ministry know that a patient is complex?

This is currently being developed by the Ministry. We will provide an update as more information is released.

Virtual Care

Does the SLI box have to be filled in when conducting a video call?

Currently, the SLI box needs to be filled only when using OTN. There will be more updates about the new codes on October 1, 2022.

What are the payment rules for virtual care?

When there is an existing patient relationship (rostered patient or the doctor has seen the patient in the last 24 months), the doctor will get paid equivalent to full value for video visits and 85% of full value for phone visits.

If you do not have a relationship with the patient (i.e. walk-in), the doctors will receive $20 for video visits and $15 for phone visits.

For Royal College Specialists and GP-focused practice designated physicians who deliver an eligible insured consultation service by video, that video consult will be deemed as initiating an ongoing physician-patient relationship for the following 24 months (just like an in-person visit would). Subsequent virtual visits in the next 24 months between the patient and that physician will be comprehensive virtual services (where video is paid at par to in-person care and telephone visits are paid at 85 per cent).

How does the changes impact a physician returning from a maternity leave? Will the Ministry take the in-person care rendered by the locum into consideration when determining the type of payment (i.e. 85% of the fee submitted or $15) to be paid to the host physician when a virtual phone visit is rendered to a patient after returning from a maternity leave? 

If the patient is enrolled, it doesn’t matter how long it has been since the patient was seen by the enrolling physician (or another physician within the group).  As for non-enrolled patients, being seen by the locum will not matter for the returning physician.  If they are not enrolled nor not been seen by the physician in the last 24 months, the discount will apply.

Rejected Billings and Reconciliation

When does the 3-month vs. 6-month billing submission deadline take effect?

This will be effective April 1, 2023. 

General

Are there any changes to K030 and Q040 virtual billings?

No. One K030 must be in person every 12 months to qualify for the Q040 when three DXM visits are done.

Do INR checks G271 and FIT counseling Q150 codes count towards the 88 visits per week?

It will only be the patient encounters, i.e., visits that count.

How does the Ministry define “weekly encounters”?

A weekly encounter is any encounter with the patient. FHO physicians are encouraged to meet or exceed the following parameters: 88 face-to-face and virtual patient encounters/week (pro-rated for 1300 enrolled patients) with at least 60% being in-person visits.

What is a complex continuing care facility?

A Complex Continuing Care (CCC) unit provides hospital care for patients with complex medical conditions requiring restorative care.

The CCC provides:

  • Transitional care to support patients and their families as the individual returns to a community setting.
  • Support for end-of-life care.

What is going to be considered complex? Will mental health count?

The new Complex Care Capitation payments will be released April 2023.

Resources

Here are some resources we have created to help doctors better understand the new Physician Services Agreement:

Do you need help understanding the Physician Services Agreement and how it affects you? Contact us today. We are happy to help!f

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