Common OHIP Billing Mistakes That Cost Ontario Physicians Money — and How to Avoid Them
Submitting an OHIP claim is only one part of ensuring that a physician receives the correct payment for services provided.
Even when a service is eligible for payment, incomplete billing information, incorrect fee code combinations or overlooked patient encounters can result in delays, rejected claims or lost revenue.
Some billing problems are identified by the Ministry of Health through Claims Error Reports or Remittance Advice. Others are more difficult to detect because the claim was never submitted in the first place.
For physicians managing their own OHIP billing, understanding these risks and establishing a consistent billing routine can help prevent avoidable errors.
1. Missing or incomplete billing information
One of the most common causes of OHIP claim rejections is missing or inaccurate information.
A physician may have provided an insured service and selected the correct fee code, but the claim can still be rejected because a required field is missing or incorrect.
Common examples include:
An incorrect health card number or version code.
A missing or invalid referring physician billing number for a consultation.
A missing or invalid diagnostic code.
Missing facility information or an admission date when required.
An incorrect date of service.
These errors often occur because the necessary information was not captured when the patient was seen.
For example, a physician may complete a consultation but discover later, while entering the billing, that the referring physician's billing number was not recorded. Obtaining the missing information can require additional follow-up and delay submission.
How to avoid this mistake
Establish a consistent process for collecting the information required for billing at the time of service.
For physicians working in clinics, health card validation can help identify incorrect patient information before claims are submitted. In hospital settings, where validation may not be as readily available, accurate patient and referral information remains particularly important.
Reviewing claims for missing required fields before submission can also reduce avoidable rejections.
For more information about identifying and correcting rejected claims, see our article Why Was My OHIP Claim Rejected? Understanding Error Reports, Remittance Advice and What to Do Next.
2. Incorrect fee code combinations and misunderstanding OHIP billing rules
Selecting the correct OHIP fee code for a service does not necessarily mean that it can be billed alongside every other service provided.
The OHIP Schedule of Benefits is more than a list of fee codes and payment amounts. It also contains definitions, conditions, limitations and payment rules that determine when particular services are eligible for payment.
One common mistake is billing services together when the Schedule of Benefits does not permit the combination.
For example, a physician may provide more than one service during the same patient encounter. Although each service may have an associated fee code, OHIP may restrict whether those codes can be claimed together or consider one service included in the payment for another.
Similar restrictions may apply to services provided on the same day, the frequency with which certain services can be billed, or the addition of premiums to assessments and procedures.
A physician may also be familiar with a commonly used fee code without fully understanding all the conditions that apply to it. Eligibility may depend on the type of service performed, the patient's circumstances, the location of the service or other billing requirements.
These misunderstandings can result in reduced payments, unpaid claims or eligible services not being billed appropriately.
How to avoid this mistake
Become familiar with the Schedule of Benefits rules for the services you provide most frequently, including restrictions on combining fee codes and claiming additional premiums.
Before submitting unfamiliar code combinations, consider whether:
The services are separately payable or one is included in another.
The combination is permitted under the applicable billing rules.
Any frequency or same-day restrictions apply.
Additional premiums or fees meet their specific eligibility requirements.
Supporting documentation or other claim information is required.
When using a new or unfamiliar fee code, review the applicable Schedule of Benefits requirements rather than relying solely on the fee description.
Billing software can help identify certain incompatible combinations, but understanding the underlying rules remains important.
Because the Ministry periodically updates the Schedule of Benefits and related billing guidance, physicians should also stay informed about changes affecting their commonly used codes.
3. Allowing billings to accumulate into large batches
One of the more easily overlooked billing risks is allowing patient encounters to accumulate before entering and submitting claims.
For physicians who manage their own billing, entering a large batch of patient encounters at once can increase the risk of overlooking individual patients or services.
This problem is different from submitting an incorrect claim.
When a claim contains invalid information, the Ministry may identify the problem through a Claims Error Report. When a claim is processed but not paid as expected, the issue may appear on the Remittance Advice.
But when a patient encounter is never entered or submitted, there is no rejected claim or payment adjustment to alert the physician.
The omission may remain unnoticed unless the original patient list or billing records are compared against the claims actually entered.
Why reviewing billing entries matters
At AE Medical Billings, our billing process includes multiple levels of review.
One team member enters the billings, a second person checks the entries against the original billing records, and a final review confirms that corrections identified during the checking process have been completed.
In our experience, larger batches are where we most frequently identify patients who were initially overlooked.
For physicians managing their own billing, a similar review process may not always be practical. However, even a basic comparison of the original patient list against the entered claims can help identify missing encounters.
How to avoid this mistake
Submit smaller batches more frequently rather than allowing billings to accumulate over extended periods.
Before submission, compare the claims entered against the original billing sheets, appointment records or patient lists to confirm that every eligible encounter has been accounted for.
Where practical, perform a second review of the entries, particularly when processing larger batches.
The goal is not simply to submit claims on time. It is to make sure that all services intended to be billed have actually been entered.
4. Treating claim submission as the end of the billing process
Another common mistake is assuming that once claims have been submitted, the billing work is complete.
In reality, submitting a claim does not guarantee that it has been accepted for processing or paid at the expected amount.
Claims may be returned on a Claims Error Report because of invalid information. Other claims may be processed but receive reduced or no payment because of OHIP billing rules.
Without reviewing these reports, physicians may not realize that follow-up is required.
This is particularly important for physicians managing their own billing while balancing clinical responsibilities.
How to avoid this mistake
Establish a routine that includes reviewing Claims Error Reports after submission and reconciling the monthly Remittance Advice against the original billings.
Claims returned on an Error Report should be corrected and resubmitted where appropriate.
Claims that have already been adjudicated but remain unpaid or adjusted should be reviewed to determine whether the payment decision is correct or whether a Remittance Advice Inquiry is warranted.
Regular reconciliation helps identify outstanding claims and ensures that eligible payments are not overlooked.
For a detailed explanation of these processes, see our guide to OHIP Claim Rejections and Error Codes.
5. Building a more reliable OHIP billing routine
Avoiding billing mistakes does not necessarily require a complicated process.
For physicians who manage their own billing, a few consistent practices can make a meaningful difference.
Capture complete information. Record the necessary patient, referral and service details when the encounter occurs.
Understand the billing rules. Review the Schedule of Benefits requirements for commonly used codes, especially when combining services or adding premiums.
Enter and submit billings regularly. Smaller batches can be easier to review and reduce the opportunity for missed patient encounters.
Check entries against the original records. Confirm that every patient and eligible service intended for billing has been entered.
Review Claims Error Reports. Correct errors promptly rather than allowing rejected claims to accumulate.
Reconcile monthly payments. Compare the Remittance Advice with submitted claims and investigate unexpected adjustments or unpaid services.
A consistent process helps reduce avoidable errors and makes it easier to identify problems before they become difficult to resolve.
The bottom line
Not every OHIP billing mistake results in a rejected claim.
Some mistakes are identified through Ministry reports and can be corrected. Others, particularly patient encounters that were never entered or submitted, may go unnoticed without a reliable checking process.
Incomplete information, incompatible fee code combinations and large batches of unreviewed billings are all risks that can be reduced through better billing practices.
For physicians managing their own OHIP billing, regular submission, careful review and an understanding of the applicable payment rules are essential to ensuring that eligible services are billed accurately.
Official OHIP resources
For current Ministry guidance and billing requirements, refer to:
OHIP Schedule of Benefits and Fees — Official fee schedules, billing rules and payment requirements.
Resources for Physicians — Ministry information about OHIP billing, electronic services and claims processing.
Claims Submission — Guidance on submitting claims, reviewing error reports and following up on payment issues.
