Physician billings: WCB payment program

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Introduction

We want to help physicians understand when it’s appropriate to bill the Ontario Health Insurance Plan (OHIP) using the WCB payment program. The Workplace Safety and Insurance Board (WSIB) pays the cost of services billed using the WCB payment program with money paid into our Insurance Fund by Ontario employers. We need to ensure that these employers aren’t paying for services that should be covered by the Ministry of Health and Long Term Care (MOHLTC).

You can use the information in this document to help you decide when it’s appropriate to use the WCB payment program. It is an offence under the Workplace Safety and Insurance Act (WSIA) for anyone to make a false or misleading statement to the WSIB.

Physician billing wizard

Ask the patient if the injury/illness happened at or as a result of work. The response is:
Ask the patient if they have or intend to claim WSIB benefits. The response is:

Answer

Bill MOHLTC

Answer

  1. Bill the MOHLTC for insured services using the MOHLTC Schedule of Benefits and the WCB payment program. For example, use the code A001 for minor assessment or A007 for intermediate assessment. The WSIB and the MOHLTC have a billing agreement in place and joint MOH/WSIB audits occur periodically.
  2. After the patient’s first visit, complete and submit the appropriate Health Professional’s Report (e.g. Form 8) to the WSIB.

Answer

The OMA has set out guidelines for physicians to follow in the Physician’s Guide for Uninsured Services (January 2017 ed. p.26 – “physicians must, a) respect their patient’s request and not report the injury to WSIB, but b) refuse to bill their medical services to OHIP”) .  You can direct your patient to the WSIB’s What workers should know about reporting workplace injuries and illnesses fact sheet on our website.

FAQs

1. What should I do after seeing a patient who is claiming WSIB for a work related injury/illness?

  1. Bill the MOHLTC for insured services using the MOHLTC Schedule of Benefits and the WCB payment program. For example, use the code A001 for minor assessment or A007 for intermediate assessment. The WSIB and the MOHLTC have a billing agreement in place and joint MOH/WSIB audits occur periodically.
  2. After the patient’s first visit, complete and submit the appropriate Health Professional’s Report (e.g. Form 8) to the WSIB.

2. How should I bill when I have received a request for medical information from the WSIB?

  1. If you have a WSIB billing number, you will automatically be paid by the WSIB for forms, reports and for telephone calls initiated by the WSIB.
  2. If you don’t have a WSIB billing number, you can refer to the WSIB’s physician fee schedule to bill the WSIB directly.

3. A patient who has a WSIB claim is seen for a non-work related illness or injury. How should the visit be billed?

If the visit is for a concern that is not related to the patient’s WSIB claim, you should bill MOHLTC using the appropriate billing code

4. A patient advises that their employer is requiring flu shots for all employees. Can I bill this to the WSIB?

No. The requirement for a flu shot is not related to a workplace injury, illness/disease, therefore this would not be an appropriate service to bill to the WSIB.

5. The worker did not attend a booked WSIB appointment. The medical office policy is to charge patients a fee for missed appointments. Can I bill the worker or the WSIB for the missed appointment?

Patients being treated for work-related injuries covered by the WSIB should not be charged for missed appointments. The WSIB only pays for treatments or services and therefore will not pay for missed appointments.

Under s. 33(5) of the WSIA, “No health care practitioner shall request a worker to pay for health care or any related service provided under the insurance plan.”

6. How do I get paid if the injured worker does not have an Ontario health card?

The WSIB will pay for the services provided. Please complete a Provider Payment Request form (PDF), then mail or fax it to the WSIB. A WSIB claim number must be included on the form. Alternatively, you may submit an invoice to the WSIB. The invoice must include the claim number and clearly indicate that the injured worker does not have a valid Ontario health card.

7. What should I do if the patient does not want the work-related injury/illness reported to the WSIB?

The OMA has set out guidelines for physicians to follow in the Physician’s Guide for Uninsured Services (January 2017 ed. p.26 – “physicians must, a) respect their patient’s request and not report the injury to WSIB, but b) refuse to bill their medical services to OHIP”). You can direct your patient to read our webpage about Reporting workplace injuries and illnesses.

8. Are children covered by the WSIB?

Anyone employed in Ontario in an industry which is mandatorily covered by the WSIA is automatically covered by the WSIB in the event of a work-related injury or illness, regardless of the age of the patient.

9. Are migrant or temporary foreign workers covered by the WSIB?

Anyone employed in Ontario in an industry which is mandatorily covered by the WSIA is automatically covered by the WSIB in the event of a work-related injury or illness, regardless of their immigration status.

Did you know?

We encourage health professionals to submit forms to the WSIB electronically. The benefits of on-line submission of forms include an increased fee and faster payment. To register for electronic billing, please go to: