Dr. Jane Healey, a pediatrician in the Greater Toronto area and section chair of pediatrics for the Ontario Medical Association (OMA), recently found herself in that terrifying boat. This experience propelled her to advocate for greater transparency and fairness in the major publicly-funded Ontario health insurance billing system. After caring for her newborn who tragically died from a genetic condition within ten days of birth, Healey received an OHIP claim denial just as painful as the loss of her newborn. This left her with a difficult choice: forgo her pay or ask the grieving parents to navigate the bureaucratic maze of Service Ontario.
Part of Healey’s mission seems to be airing her grievances about OHIP billing woes. She illustrates her journey by showing how so many healthcare providers are suffering from this shared systemic ailment. Healey points out that caring for patients is taking an emotional toll on the healthcare workers. This burden frequently runs counter to the administrative realities of navigating the healthcare system.
The Emotional Toll of OHIP Billing
Dr. Healey’s experience reflects a significant problem within Ontario’s healthcare framework. In her moving presentation, she told us that the work she does alongside her educator colleagues requires a high degree of emotional labor. This is particularly the case in critical care and end-of-life contexts.
“That means that we aren’t remunerated for some of that very difficult, highly emotional work that stays with you,” – Dr. Jane Healey
With over 200 million OHIP claims processed annually, the statistics reveal a troubling reality: approximately 1.16 million claims are rejected each year, necessitating a manual review process that can take months. As Healey’s case illustrates, they can have a devastating impact on both healthcare providers and patients.
Dr. Zainab Abdurrahman, another physician in the OMA, deepens the conversation. She emphasizes the challenges providers experience with the manual audit process, calling it a steep hill to climb.
“They’re thinking, ‘wow, I’m just going to have to be fighting to prove that I already did this work,’” – Dr. Zainab Abdurrahman
Our nation’s healthcare providers are under unprecedented emotional and financial duress. This unrealistic pressure frequently distracts them from patient care, which is causing mounting cries to change the broken status quo.
The Need for Systemic Change
The OMA has been advocating for the establishment of an OHIP ombudsman office. This office must be populated with clinical billing experts to help address these complicated billing issues first-hand. Many healthcare professionals argue that having individuals without clinical expertise reviewing claims leads to misunderstandings and delays, further complicating an already challenging situation.
“Having people who are reviewing operating room notes or various physicians’ technical notes who don’t have clinical expertise, that isn’t matching up. So that’s causing issues,” – Dr. Zainab Abdurrahman
The trade association points out that over 95 percent of intricate surgical claims get a resolution within a month. Today’s system breaks down on more complicated cases, making them take much longer, sometimes years, to be resolved.
Dr. Healey and her colleagues are advocating to change the process. They’d like to make sure that every provider can get paid quickly, even in the most emotionally heated circumstances, such as hers.
The Broader Implications
These billing issues are about far more than individual cases. Most dangerously of all, they threaten to stifle innovation from outside Ontario’s healthcare system.
“So, we’re also potentially stifling innovation within the province,” – Dr. Zainab Abdurrahman
Ema Popovic, a fellow OMA member, expressed her frustration concerning the focus on the very small percentage of claims requiring manual review. She argues that this focus is culpable for directing attention away from major strides made in the area of physician support.
“It’s disappointing that the OMA is focusing on less than one percent of claims that require a manual review rather than highlighting the real progress we’ve made together to support physicians,” – Ema Popovic
