As the fiscal year-end date of March 31 approaches, we want to remind family physicians practicing in Ontario about the Preventive Care Bonus and the recent changes introduced in 2024 under the new Physician Services Agreement (PSA).
This bonus has been an important and valuable incentive for providing preventive screenings and immunizations for enrolled patients. Following the recent changes, we’ve received many inquiries from our doctors seeking clarity. Notably, for FHO and FHN physicians, this bonus has been reduced and partially replaced by the Acuity Modifier. For those in CCM and FHG payment models, the bonus remains fully available, while recently transitioned FHO doctors may still qualify under certain conditions.
This blog will cover key information on the Preventive Care Bonus, including eligibility criteria, billing requirements, and recent changes. We will also share practical strategies to help FHO members offset the impact of reduced bonuses and maintain current revenue streams.
What is the Preventive Care Bonus and its Categories?
The Preventive Care Bonus is a financial incentive for eligible family doctors who provide timely and regular preventive screenings and immunizations for their rostered patients.
The bonus covers five preventive care categories with specific age and interval requirements:
Category | Age Group | Interval |
Influenza Vaccine | 65+ | 1 per year |
Childhood Immunization | 2.5-3.5 | All by 2.5 years |
Pap Smear | 21-69 | 1 every 3 years |
Mammogram | 50-74 | 1 every 2 years |
Colorectal Screening | 50-74 | 1 every 2 years |
Who is Eligible for the Bonus?
Eligibility for the Preventive Care Bonus depends on the physician enrollment model:
- Eligible: CCM and FHG physicians.
- Partially Eligible: FHO and FHN physicians.
- Not Eligible: FFS physicians.
For CCM and FHG physicians, eligibility requires a minimum of 650 rostered patients. Only services provided to rostered patients count toward the bonus calculation.
How to Calculate and Bill the Preventive Care Bonus?
The Preventive Care bonus offers up to $12,800 in potential earnings for physicians who achieve high screening and immunization rates. On average, physicians earn approximately $8,500 but with proactive efforts and strategic billing, this amount can be increased.
Billing for the Preventive Care Bonus involves submitting specific service, tracking, and exclusion codes. These codes ensure accurate reporting of completed services and help identify patients who qualify or are excluded.
Bonus levels are based on the percentage of demographically targeted patients screened or immunized. For example, if 75% of women at risk (i.e. between the ages of 50 and 74) in a physician’s roster are screened for cancer via a mammogram, the physician would be eligible for a bonus of $2,200.
There is a full list of Fee Schedule service codes that are applicable for each Preventive Care Bonus category. Tracking codes are billed at $0 to document service completion, while exclusion codes are used to help identify patients who do not meet target population criteria.
To receive their preventive care bonuses, physicians need to:
- Calculate their screening levels individually.
- Submit the appropriate billing code for the level of screening within that category.
To determine your screening level, use the following formula:
(Number of screened patients / Target Population – Excluded Patients) x 100
Preventive Care Bonus Submission Timeline
To support physicians, the Ministry of Health sends preventive care target population reports twice a year in April and October. Submissions with a service date up to March 31 of the previous year, must be made by the June 18th in order to claim the bonus.
Since this bonus occurs only once a year, it can be easy to overlook. That is why it’s important to begin screening patients and submitting the required tracking codes well in advance of the March 31st deadline to ensure you don’t miss out.
Our comprehensive Preventive Care Quick Reference Guide provides more detailed information on the bonus categories, relevant codes and their usage, how to determine your capture levels and bonus amounts, and steps to claim your bonus.
2024 Preventive Care Bonus Updates for FHO and FHN Physicians
For the fiscal year 2024 (April 1, 2024, to March 31, 2025) and billable April 1, 2025, onwards, FHO and FHN physicians will no longer be eligible to receive the Colorectal Cancer, Mammography, and Pap Smear Preventive Care Bonuses, as agreed upon between the Ministry and the OMA. They will continue to be eligible to receive the Influenza and Childhood Immunization bonuses with these adjustments:
- Physicians with less than 1,000 enrolled patients will have the remaining bonuses prorated.
- Physicians with 1,000 enrolled patients or more, will not have the remaining two bonuses prorated, and will bill per status quo.
These changes aim to repurpose funding toward supporting complex patient care through the introduction of the Acuity Modifier.
The New Acuity Modifier Update
With the Ministry’s decision to discontinue Preventive Care Bonuses in three categories for FHO and FHN physicians, these changes have sparked ongoing discussions within the medical community. In response, the OMA has introduced a new Acuity Modifier payment structure, designed to reallocate the funds and ensure continued compensation for the care of complex patients, helping to offset the impact of these adjustments.
This new system calculates patient risk scores based on age, sex, activities of daily living, and health conditions using the Canadian Institute for Health Information’s Population Grouping Method. These scores determine each patient’s acuity band, ranging from Band 1 (least complex) to Band 5 (most complex), with higher bands yielding increased compensation, recognizing the additional time and resources required for complex cases.
For a detailed explanation of acuity bands and related payments, visit our blog: Acuity Modifier Payments: Boosting Compensation for Complex Patient Care.
Physicians do not need to calculate the acuity bands; the Ministry assigns them based on diagnostic codes. Doctors should focus on using precise diagnostic codes in their patient visits to ensure proper assignment to bands to maximize capitation.
We have developed a Diagnostic Codes Quick Reference Guide to assist you in selecting the most appropriate codes for accurately representing your patients’ conditions.
Maximizing Lost Revenue: Practical Strategies
If you no longer qualify for the Preventive Care Bonus, can you offset reduced revenue? Recovering income affected by recent changes requires a more strategic approach to billing practices and patient care. We have found regular roster management, and systematized patient recalls to be particularly effective strategies for addressing these challenges. Too often, physicians miss these areas, foregoing opportunities to stabilize their income and enhance patient care.
Effective Roster Management
A discrepancy of 100–150 patients between your EMR and the Ministry’s records can lead to $10,000–$20,000 in unrealized annual capitation income. Regularly keeping track and maintaining an accurate patient roster is critical for maximizing revenue potential.
DoctorCare’s Patient Care service offers a comprehensive solution for regular roster management, including identifying non-rostered patients, sending rostering forms, and billing rostering codes. By leveraging this service, you can minimize discrepancies and ensure your capitation payments reflect your actual patient roster.
Streamlined Patient Recalls
Many practices struggle with inefficient patient communication and recalls, due to their busy schedules. A systematic approach to recalls is essential for providing effective preventive care and managing chronic conditions, such as diabetes or congestive heart failure.
Another component of our Patient Care service includes tailored solutions for patient recalls, ensuring proactive communication and follow-up. We help you manage key preventive screenings, such as diabetic patient recalls, to optimize your Q040 submissions and ensure no missed bonus payments due to overlooked check-ups.
By implementing these strategies, you can minimize revenue losses and continue providing high-quality care to your patients.
Conclusion
The latest changes to the Preventive Care Bonus reflect the changing landscape of healthcare compensation. By staying informed and taking a proactive approach, you can adapt to these changes while delivering exceptional care. From strategic billing and accurate diagnostic coding to leveraging our Patient Care Program, effective tools and strategies are available to support your success.
Don’t wait until the March 31 deadline—reach out to us today to optimize your billing practices and maximize your bonus potential!
