Every medical regulatory body across Canada has a standard or policy for physicians providing virtual care and these standards and policies vary throughout the country. These standards and policies also include instructions and restrictions for how physicians providing virtual care must bill to receive payment for their services.
Due to the increased need for virtual care throughout the pandemic, several provinces developed temporary systems and codes for physicians to use to bill for virtual care. However, the standards and processes for physicians to receive payments, or even to provide virtual care, continue to vary from province to province.
Here’s how current policies for virtual care billing in Ontario differ from those policies in British Columbia, Saskatchewan, and Nova Scotia.
Virtual Care Payment Plans in Canada
Before analyzing virtual care billing processes in Ontario and across other provinces, it is important to recognize that there are two main types of virtual care billing processes in Canada, alternative payment plans and fee for service (FFS).
What is Alternative Payment Plan?
Alternative payment plans operate on the notion that care will be provided most efficiently and effectively for the patient. Payments can be made in a variety of ways, including capitation, bundled payments, block payments, salary, or blended models. Two advantages of alternative payment plans are that they do not restrict physicians from being paid through alternate models, and they readily adapt to changes in patient preferences and technology. Alternative payment plans are currently only in use in the Northwest Territories.
What is Fee for Service (FFS)?
FFS operates on the premise that physicians must use codes for a specific type of care (e.g., communicating with a patient via telephone, email or text) to be eligible for compensation. In some provinces, the billing infrastructure for virtual care is severely lacking; while many physicians are glad to communicate with their patients via video, phone, email or text, they may not be compensated for their time and efforts. While FFS is the more prevalent payment method across the country, the lack of compensation may deter physicians from providing virtual care or communicating with patients.
For more information about the alternative payment plans and FFS, please see the Virtual Care Task Force Report.
Ontario’s Virtual Care Billing Process
Ontario’s Virtual Care Program, formerly referred to as the Telemedicine Program, was updated in November 2019 to include direct-to-patient video visits and to modernize virtual care compensation. The complete billing manual is available here.
Physicians must submit claims for virtual care through the Ontario Health Insurance Plan (OHIP) claims processing system. A summary of key points from the billing manual follows:
- Physicians must complete register via the Ontario Telemedicine Network (OTN) with the Ministry of Health to be eligible to receive payment for virtual care services
- Physicians and patients must use an approved OTN video solution
- The physician and the patient must be located in Ontario for the physician to receive compensation for virtual care services
- The physician must use an appropriate fee code included in the virtual care program
- Virtual care claims must be received and processed by OHIP within six months from the date service was provided
While the summary above is not exhaustive, it provides a brief overview of the requirements for physicians to obtain payment for virtual care services in Ontario. OHIP released two temporary codes for virtual care services for physicians during the pandemic in late March 2020 and followed up with additional temporary codes in September 2020.
Virtual Care Billing Processes in Other Provinces
Billing Process in British Columbia
British Columbia has the most comprehensive approach to FFS for virtual care billing purposes. Ontario’s process ranks second according to the Virtual Care Task Force Report. British Columbia has three permanent categories of virtual care eligible for billing – telehealth (health services delivered by a physician via live image transmission through an approved video technology site), medical management via telephone, and emailing or texting medical advice to patients. British Columbia does not require physicians to be licensed in the province to provide virtual care.
Billing Process in Saskatchewan
In Saskatchewan, payments for telemedicine services are limited to approved facilities and practitioners who must both be located within the province. Telephone fee codes are limited to very specific matters, including remote nurses, monitoring anticoagulant therapy, monitoring patients with diabetes who are on insulin, and remote consultations between physicians. Emails, telephone calls, and faxes from recognized health professionals may be billable as long they meet province-wide criteria. Saskatchewan is currently funding several pilot projects related to virtual care, and this may impact billing processes in the future. According to the Virtual Care Task Force Report, Manitoba observes similar virtual care billing processes.
Billing Process in Nova Scotia
Like British Columbia, physicians in Nova Scotia are not required to have a provincial license to provide virtual care. The province was making substantial progress in offering virtual care; the provincial government had supported a pilot project to provide telephone and e-health services called MyHealthNS. Family physicians who enrolled their patients in the program could receive up to $12,000 per year for using technology to communicate with their patients. Over 320 health-care providers and 38,000 patients used MyHealthNS before this project was sidelined in the spring of 2020 due to the technology provider, McKesson Canada, not renewing their contract with the province.
A comparison summary of billing policies in different provinces
|Registeration in province Required
|Proivnce approved solution required
|Telehealth services provided
While most provinces are making progress to provide physicians with viable billing policies for services, the processes vary across the country and physicians are providing virtual care services without being reimbursed. According to the Virtual Care Task Force Report, there is a pan-Canadian system of medical service payment with interprovincial reciprocal billing agreements, but it will need to be adapted to meet the changing needs of virtual care for physicians and patients across the country.
The healthcare industry has been evolving at a rapid pace since the onset of the pandemic as clinicians and healthcare providers look to improve access to care for patients. Thankfully, Telemedicine and Telehealth has made it easier for healthcare professionals to communicate and collaborate with their patients, thereby removing the hurdles which sometime delay access to medical care. A recent survey conducted by Canada Health Infoway which shows that 74% Canadians believe digital health has a positive impact on Canadian health system is a testament to that fact. And while Telehealth and Telemedicine are two of the most used terms in Canadian Healthcare industry not many know that these two terms cannot be used interchangeably. In fact, Telehealth and Telemedicine refer to two different segments of remote healthcare.
Telehealth refers to the extensive use of electronic records and information along with telecommunication technologies to provide long-distance health care including patient health education and resources, public health, and even health administration. Here are some common ways that Telehealth can be delivered:
- Video Consults and Conferencing – Video conferencing and video consults have rapidly grown in popularity since late 2019. Video consultations refer to real-time, two-way interaction between patients and clinicians which support health care services. Today, platforms like Microsoft Teams enable safe care coordination and consults while providing access to healthcare records in a single space for providers. One prime example of this type of telehealth service is a specialist examining a patient over a live video feed. Another example could be a remote training session broadcast from an academic medical center for physicians at a provider facility.
- Mobile Health – Mobile health is also referred to as mHealth and it is primarily used to deliver health information over mobile devices such as tablets and smartphones. With the advent of patient portals and apps Mobile Health has grown exponentially over the past few years in Canada- 32% of Canadian adults consult health apps on their mobile devices. An example of such kind of telehealth service includes preoperative instructions texted to a patient to prepare for a surgical procedure.
- Remote Health Monitoring or Remote Patient Monitoring (RPM) – Remote patient monitoring is gathering and transmitting of patient data to providers from patients location, often outside of traditional healthcare settings using information technology. The data gathered may include medical data such as blood pressure, blood glucose and blood oxygen readings.
- Other Asynchronous Services – Transmission of medical reports and scans fall into asynchronous services as there is no-real time interaction between clinician-clinician, or patient-clinicians.
Telemedicine vs Telehealth, in contrast, is limited in context to just delivery of clinical care. Telemedicine, therefore, is restricted to delivering care through use of telecommunication technology. Some basic examples of Telemedicine would therefore include:
- Remote videoconference for the purpose of supporting diagnosis, treatment, and prevention of diseases or injuries.
- Remote monitoring and support of a patient’s medical condition after therapy or surgery.
- Post-op follow-up visit through text message, phone call, or video conference.
- Post-op transmission of vitals such as blood pressure data, ECG, and blood sugar levels.
- Remote video conference consult with a medical specialist and coordination of care over platforms like Microsoft Teams.
- Remote management of a chronic condition.
How to differentiate Telehealth vs Telemedicine
- Not all videoconferencing is Telemedicine. For example, a videoconference between a health specialist and his medical students is telehealth since it’s non-clinical. However, a video consult between a patient and a doctor would be termed telemedicine since it relates to a clinical relationship which helps provide care.
- Not all asynchronous medical services are Telemedicine. For example, an academic publication intended to be used for education purposes is Telehealth but sharing an MRI scan of a patient digitally would be called Telemedicine.
- Not all mobile health services are Telemedicine. For example. A community health update or warning would be considered Telehealth, but providing instructions to patients for post-op followup would be called Telemedicine.
Virtual health care visits are a boon for a health care system under severe strain due to the ongoing pandemic. With the increased need for virtual health care visits across Ontario, there has been a lot of focus on privacy requirements related to facilitating appointments and ongoing care. The ability to offer virtual care across the province aligns with Ontario’s Digital First for Health strategy, an initiative announced in late 2019 that was very timely because in-person health care visits were cut-back in 2020 due to COVID-19. For health care providers, service providers, patients, and other stakeholders, it is especially important to be aware of provincial privacy and data security requirements to continue promoting virtual health care in Ontario as a viable method to share health-related data to provide and receive care.
The Personal Health Information Protection Act and Virtual Health Care in Ontario
The legislation governing virtual health care visits and sharing personal health information in Ontario includes the Personal Health Information Protection Act (PHIPA) and Ontario Regulation 329/04/. Personal health information (PHI) is defined as an individual’s information in relation to health care services. PHI includes, but is not limited to, the following:
- Telephone number
- Health card number
- Health care provider’s name
- Reason for the appointment referral
- Examination results
One of the first initiatives under Digital First for Health strategy in Ontario is to modernize PHIPA and clearly define how individuals and organizations use PHI. In collaboration with the Ministry of Health, Ontario Health and OntarioMD, province-wide standards have been developed to ensure that front-line health care providers can offer secure, confidential virtual appointments through two modalities, video, and secure messaging.
Some Basic Principles to Comply with PHIPA
1. Keep health records updated
All clinical and administrative data must be kept up to date. Any individual request to correct a record must be done within 30 days. If any clinical or administrative change has been made to patient records, then the same information must also be disclosed to the individual concerned as well. Virtual health solutions with capability to modify, update or notify providers of requested changes automatically follow this compliance guideline.
2. Keep health records secure
All PHI must be protected from theft, loss, and unauthorized use. This can be done by following proper procedures while ascertaining the type and location of the data centre. A SOC 2 data centre is considered a good practice because it follows a set of predefined benchmarks for privacy, security, confidentiality, and availability.
3. Store records for appropriate time frames
For any records requested by an individual or authorities, the records must be kept unchanged until all procedural matters are resolved related to any query/complaint. In this context, designating a privacy contact person is particularly important to oversee stored records’ compliance.
Standards for virtual visit solutions are intended to ensure care services are delivered using safe, secure, and interoperable platforms. These standards were developed in collaboration with health care organizations and clinicians across Ontario. The process to obtain recognition as a Virtual Visits Solution Standard is detailed here; all verified solutions will be posted here on OTN’s website in the future.
Virtual mental health services and solutions have increasingly become critical areas of support during the COVID-19 pandemic. As a part of provincial mental health and addiction response package of over $147 million, the Ontario government plans to provide $15.4 million to expand virtual mental health and addictions support and build a connected system for easier access to people.
The plan is aiming to make it easier for Ontarians across the province to access resources, including internet-based Cognitive Behavioral Therapy, virtual addictions supports and virtual supports for health care workers. This funding is also expected to help provide virtual services for children and youth through the Kids Help Phone and Child and Youth Tele-Mental health services. Health care workers will also benefit from this investment and continue accessing virtual mental health services.
The pandemic has had severe impact on mental health of those already suffering due to prolonged physical distancing, financial uncertainty, and the fear for the well being of family members. Since the outbreak, life has increasingly become difficult for many people and families across Ontario, especially among those living with mental health and addictions challenges.
It is therefore important that this relief packages also aims to provide over $62.2 million funding in community-based mental health and addictions services and inter-professional primary care teams, with $30 million specifically marked to fund child and youth mental health services. The services which will benefit from these investments include local in-person and virtual community mental health and addictions services, housing and accommodation supports, capacity-building for front-line workers, peer supports and resources, and enhanced services through interprofessional primary care including Family Health Teams, Indigenous governed supports, and Community Health Centres.
As part of the extended Ontario’s Fall Preparedness Plan, Keeping Ontarians Safe: Preparing for Future Waves of COVID-19, this investment will build on the $46.75 million in emergency funding for mental health and addiction services granted in the first phase of the COVID-19 outbreak. Since the beginning of the pandemic, the Ontario government has invested a total of up to $194 million in its COVID-19 mental health and addictions response and while this may be enough to weather the dark winter, a focused approach in building virtual healthcare capacity is required to truly affect a foundational change in healthcare in Ontario.
Canada was one of the first nations to offer virtual care in the 1970s. The late Dr. Maxwell House conducted appointments via telephone to expand his reach to patients in remote areas across Newfoundland. Despite Dr. House’s innovative efforts just under four decades ago, many patients are still required to travel to see their doctors in Canada. The infrastructure to care for Canadians through modalities other than face-to-face appointments in a physician’s office, such as tele-medicine, is not new; the technology required to facilitate virtual health care has existed for decades. Despite the presence of available technology, widespread adoption of virtual health care systems has not occurred in Canada. While most Canadians view virtual health care as a viable option, the three main obstacles to widespread virtual health care adoption in Canada are:
- Lack of Country-wide Coverage and Payment Options for Physicians – The Canada Medical Act, passed in 1912, created the Medical Council of Canada for the purpose of establishing a pan-Canadian standard for portable eligibility of licensure. It exclusively covers emergency care for individuals temporarily outside their home jurisdiction, and any other care requires prior approval to be covered by insurance. This legislation makes it challenging for physicians to provide patient care, and to receive payment. There is a limited number of physician payment models in Canada; as a result, virtual care is growing faster in the private non-insured sector (outside of provincial medical care plans).
- Physician Licensing Inconsistencies – Depending on the province or territory, physicians may have different requirements to provide virtual care to patients. For example, Saskatchewan offers a specific telemedicine licence and New Brunswick permits physicians from other jurisdictions to provide telemedicine services through a telemedicine regulation. However, British Columbia, Ontario, Nova Scotia and Newfoundland do not require physicians to be licensed in their province or territory to provide virtual care. In a recent survey on virtual care in Canada, 91% of Canadian physicians supported creating a pan-Canadian to practice in any Canadian province or territory.
- Lack of Interoperability – There are currently data-related challenges to virtual care, including sending and receiving referrals, exchanging information with clinicians and sharing information with pharmacies. In a report from the Canadian Medical Agency (CMA) on virtual care, there are several recommendations to create a pan-Canadian information architecture to uphold consistent interoperability standards for virtual care, including a framework to exchange information, a technical architecture, a patient/provider registry network and a portable method for health informatics legislation and policy.
While these obstacles to adoption of virtual care in Canada might seem too big to solve in a short period of time, other countries have built models which can become a guiding light for providers in Canada. In a discussion paper published by the CMA in August 2019, several countries have created and launched country-wide digital strategies:
- England unveiled their long-term health care plan, National Health Service, in 2018 with the goal that every patient will have a digital option for primary care within five years along with a comprehensive digital transformation strategy.
- The Kaiser Permanente system, with over 12 million health plan members in the United States, reported that half of all interactions between patients and health care teams were virtual in 2017; interactions included telephone calls (50%), secure messages (40%), scheduled telephone visits (10%) and video visits (0.2%).
- France launched Ma Santé 2022 in 2018; Ma Santé 2022 is a comprehensive strategy to clearly define digital governance, the interoperability of health information systems and advocate for a broader range of digital health services, such as telemedicine, across the country.
- Australia’s digital health strategy was released in 2018 with a focus on the importance of using digital information and technology to improve the quality of care, prevent adverse drug events, increase vaccination rates and provide care accessibility for people living in rural and remote areas.
Learning from other digital health economies, Canada is slowly paving the path forward for connected healthcare solution. New virtual care technical solutions, such as Microsoft Teams, have helped hospitals, physicians, health care administrators and many more share information, collaborate and facilitate virtual patient appointments.
Many Canadian physicians have made a concerted effort to care for patients in a “virtual first” manner due to COVID-19. While the current global pandemic has accelerated virtual care delivery, it occurred at a slower pace than the United States, the United Kingdom and several other European countries. “We’re basically witnessing 10 years of change in one week,” said Dr. Sam Wessely, a general practitioner in London during a recent interview with the New York Times. “It used to be that 95 percent of patient contact was face-to-face: You go to see your doctor, as it has been for decades, centuries. But that has changed completely.”
In May 2020, Canada’s Prime Minister, Justin Trudeau, invested $240.5 million to create, enhance and deploy virtual care and mental health tools. In collaboration with Canadian provinces, territories and stakeholders, these funds have been allocated to create digital platforms and applications, improve access to virtual mental health supports and make it possible for Canadians to meet with their regular health providers and specialist health services through telephone, text or videoconferencing. Virtual care funding at the provincial level, including an investment of $14.5 million by Ontario in December 2020, is an encouraging sign that Canada is committed to making virtual care the health care of the present and the future.
Ontario has been called out in a sweeping report published by the auditor general for moving too slow in virtual care expansion. According to the report, Ontario has lagged when it comes to integrating virtual care services with its health-care system. This report comes at a time when the healthcare sector is undergoing a massive transformation all over North America in response to the raging pandemic.
Ontario is one of the first provinces to initiate the concept of Health Teams meant to provide coordinated and connected care throughout the province. However, issues like hallway care and a growing number of retirement homes with residents who should be in long-term care are quite prominent in the province.
But that is not all, the auditor also found the Ontario Telemedicine Network (OTN), which provides remote care, and the Ministry of Health “do not have effective systems and procedures in place to offer virtual care services more long term in a cost-efficient manner to meet Ontarians’ needs.” The audit unearthed “numerous cases” where physicians had “significantly high” billings for virtual care, including one case where a doctor billed $1.7 million for remote services in 2019-2020 and another $1.9 million for in-person services. That doctor reported seeing as many as 321 patients virtually in one day, the report said.
Because of the COVID-19 pandemic, the Ministry of Health came to rescue of Ontario physicians by issuing temporary billing codes that allowed to bill for virtual-care services provided through telephone video visits, in addition to the virtual visits through the Telemedicine Network platform. While this increased data security and privacy concerns, it was an important step to providing virtual patient care during the pandemic.
But even enabling virtual health and telehealth comes with its own set of challenges. Since the onset of the pandemic, Telehealth Ontario has experienced long wait times and technical issues despite expanded capacity and resources. For example, in March 2020 i.e., the first month of the COVID-19 pandemic, Telehealth Ontario received 46,000 calls (with about half related to COVID-19), an increase of 24 per cent from February 2020. This 24 per cent increase in call volume increased the average wait time, including the time spent waiting for a call-back from Telehealth Ontario, from 1 hour in January and February 2020 to 28 hours in March for a non-COVID related phone call.
While the province is now on-pace to clock more than 2 million virtual care visits combined in 2019-2020, the pace of technology adaptation has remained slow. This is however, expected to change in the coming years as initiatives like Ontario Health Teams take shape and enable virtual connected care in the province.