Keeping Health Care Providers informed of payment, policy or program changes

To: Providers
Published by: Health Services Branch, Ministry of Health
Date Issued: August 7, 2020

To continue supporting the government’s efforts in response to the COVID-19 outbreak in Ontario, the Ministry of Health (ministry) and the Ontario Medical Association (OMA) have reached an agreement to temporarily fund payments that are equivalent to the rates in the Schedule of Benefits for Physician Services (the Schedule) for the premiums and management fees listed below when related to the provision of the temporary virtual care K-code services.

Given the ongoing COVID-19 outbreak and that necessary physical distancing continues to place limits on the ability to provide face-to-face physician services, these payments will support the provision of care in a safe environment for specialized and vulnerable patient groups that require continuity of care.

Physicians who meet all of the criteria noted below will be eligible for these payments when billing the temporary virtual care K-codes (K080, K081, K082 and K083) in the Schedule.

Eligibility for the payments that are equivalent to the Schedule rates for the listed premiums and management fees will be effective March 14, 2020, and will end when the Ministerial Order that established the temporary virtual care K-codes is no longer in force.

Temporary Payment to Family Health Group (FHG) physicians-10% Premium

• This premium will be paid automatically to FHG physicians on virtual care K-code services provided to enrolled/assigned patients. Details about this implementation will be communicated in a future INFOBulletin.

Temporary Payments Equivalent to Selected Specialist Premiums

• Specialist physicians will be eligible for payments that are equivalent to the Schedule value of the applicable premium(s) listed below when providing virtual care K-code services.

Equivalent payments will only be made for the Schedule value of the applicable specialist premiums listed in the table below:

Temporary Payments Equivalent to Selected Management Fees

• The relevant virtual care K-code services will be deemed to contribute towards the accumulations or limits for the corrresponding consultations, assessments, and visits in the Schedule payment rules for the management fees listed below.
• The eligibility of relevant virtual care K-code services towards the payments that are equivalent to the Schedule rates for the listed management fees will be communicated in more detail in a future INFOBulletin.
• If the Schedule payment rules are met through a combination of the relevant in-person or virtual care services, physicians will be eligible for payments that are equivalent to the Schedule value of the applicable management fee(s) listed below.

Equivalent payments will only be made for the Schedule value of the applicable management fees listed in the table below:

Note: The Long-Term Care (LTC) and Nursing Home Management Fee (W010) where patient care is delivered virtually is already payable with documentation of virtual visits in the patient’s chart. Physicians have been eligible for payment for W010 for virtual care since March 14, 2020, and continue to be able to bill for this management fee when appropriate.

Implementation of these Payments

While the equivalent payments to the above listed premiums and management fees are effective March 14, 2020, system changes are required to be completed in order to process some of these payments.

Temporary Payment to Family Health Group (FHGs)-10% Premium FHG Premiums:

• The applicable FHG premiums for K-code claims previously submitted, retroactive to March 14, 2020, will be adjusted automatically through the Medical Claims Adjustment (MADJ) process at a future date. More information will be provided in a future INFOBulletin.

Temporary Payments Equivalent to Selected Specialist Premiums:

• Effective immediately, physicians can now submit claims, including any previously unsubmitted claims for services provided on or after March 14, 2020, for the equivalent specialist premiums by adding the eligible premium to the fee for the appropriate service and submitting a claim for the sum of the service and premium using K083.
  • For the purpose of these K083 claims and premium payments, the total increments eligible for payment is equal to the fee listed in the Schedule for the appropriate service, plus the value of the applicable equivalent premium(s), rounded to the nearest $5, divided by 5.
  • Physicians should include all applicable equivalent premiums when submitting each K083 claim as a subsequent K083 claim on the same day on the same patient will not be payable. If a physician has submitted a claim without including all applicable equivalent premiums, these claims can only be corrected through a Remittance Advice Inquiry (RAI) submission.

• Where a physician has previously submitted claims for payments under K083 which did not include the value of any applicable specialist premiums equivalent to those listed above, physicians will have to wait to submit claims for the equivalent specialist premiums until further notice from the ministry. More information will be provided in a future INFOBulletin.

Temporary Payments Equivalent to Selected Management Fees:

• Physicians will have to wait to submit claims for the equivalent management fee payments until further notification from the ministry, which will be communicated through a future INFOBulletin once the necessary system changes have been implemented.
• Important: Claims submitted under the K083 fee code (specialist consultation or visit by telephone or video payable in increments of $5.00) must not include any management fees amounts. These are not eligible for payment using K083.
• In the meantime, physicians may continue to submit claims for the virtual care K-codes (K080, K081, K082 and K083) for the value of the appropriate consultation or visit, plus any applicable equivalent specialist premiums as outlined above.

The ministry has agreed to apply an extenuating circumstance exemption to all of the above claims in accordance with the staledated claims submission policy to allow enough time for providers to submit their claims. Further details will be provided in a forthcoming INFOBulletin.

Important Additional Terms and Conditions

By claiming and accepting the payments that are equivalent to the above listed premium and management fees, physicians will be deemed to agree to the following terms and conditions:

• Payments equivalent to Specialist Premiums (as listed above): All payment requirements in the Schedule that are applicable to specialist premiums must be met for these premiums to be payable. Where the Schedule requires a specific fee code or service, K083 will be accepted as meeting that requirement.
• Payments equivalent to Management Fees (as listed above): Where the Schedule requires that specific element(s) of physical examination(s) be completed for the year that the Management Fee is claimed (e.g. foot examination in diabetic patients), an in-person physical examination(s) must take place in order for physicians to qualify for payment equivalent to the management fee. All other payment requirements in the Schedule that are applicable to insured services also apply to these services. For these payments, virtual care K-codes will be accepted as meeting the requirements for listed consultations, assessments or visits in the Schedule.
• The same claims submission requirements for insured services in Regulation 552 under the Health Insurance Act must also be met when submitting claims for the Specialist Premium and Management Fee payments described above (e.g. including physician billing number, patient health number, etc.).

For any further inquiries, please contact the Service Support Contact Centre at 1-800-262-6524.