OMA-MOHLTC Agreement Update - April 13, 2006

Important Billing Update for Primary Care Physicians in Patient Enrolment Models

The OMA Communications Advisory Committee has prepared the following three-page summary for primary care physicians in Patient Enrolment Models (PEMs), which describes new codes and fee changes that came into effect in March and April 1, 2006. This material is intended to assist members in taking full advantage of the OMA-MOHLTC Agreement.

Primary Care Models - Comprehensive Care Management (CCM) - Community Health Centre (CHC) - Community Sponsored Contract (CSC) - Family Health Group (FHG) - Family Health Network (FHN) - Group Health Centre (GHC) - Health Service Organization (HSO) - Primary Care Network (PCN) - Rural & Northern Physician Group Agreement (RNPGA) - South Eastern Academic Medical Organization (SEAMO) - St. Joseph's Health Centre (SJHC)

Implemented March 2006

Q023A Unattached Patient Fee (Appendix H, Section 1) - Effective October 1, 2005 Eligible Models: CCM, FHG, FHN, GHC, HSO, PCN, SJHC Change: $150 per enrolment of an Unattached Patient. Context: Both the Unattached Patient and the enrolling physician must complete both the "Patient Enrolment and Consent to Release Personal Health Information" form and the "Unattached Patient Declaration" form. For any individual patient a physician may only claim one of the following fees: New Patient Fee, New Graduate-New Patient Fee, Unattached Patient Fee. A physician may submit an Unattached Patient Fee and a Per Patient Rostering Fee for the same patient. There are no limits on the number of Unattached Patient Fees a physician may claim.

Q033A New Graduate-New Patient Fee (Appendix E, Section 6.3) - Effective July 1, 2005 Eligible Models: CCM, FHG, FHN, GHC, HSO, PCN, SJHC Change: $100 per enrolment of New Patients up to and including 64 years of age. $110 for New Patients aged 65 to 74 years of age. $120 for New Patients aged 75 years of age and older. Context: Only New Graduates, physicians who have completed their family medicine post-graduate training and were licensed to practise within three years of joining a PEM or July 1, 2005 (whichever is later), may claim Q033A. Both the patient and the enrolling physician must complete both the "Patient Enrolment and Consent to Release Personal Health Information" form and the "New Patient Declaration" form. A maximum of 150 Q033A claims may be made per physician.

Implemented April 1, 2006

Expansion of Comprehensive Care Codes (Appendix E, Section 10.5) Eligible Models: FHG Change: Current group of 13 comprehensive care codes expanded to include the following codes: C010, K022, K030, K023, C882, G539, A901, A902, A008 (WSIB-related). Context: The above list of fee codes will now be eligible for the 10% comprehensive care premium when provided to rostered patients.

Q012A After Hours Premium Increase (Appendix E, Section 1.3) Eligible Models: FHG, FHN, HSO, PCN, SEAMO Change: Increased from 15% to 20% of associated fee codes. Context: Applies to After Hours/Block Coverage.

Q040A Diabetes Management Incentive (Appendix E, Section 1.3) Eligible Models: CCM, FHG, FHN, GHC, HSO, PCN, RNPGA, SEAMO, SJHC Change: Annual $60 fee per patient. Context: Paid to physicians in a PEM for enrolled diabetic patients for co-ordinating, providing, and documenting all required elements of care for diabetic patients - a flow sheet will be maintained in the patient's record, including required elements of diabetes management and complication risk assessment. To claim the incentive, a physician may submit a Q040A fee code for an enrolled diabetic patient once per 365-day period.

Q041A Add-On Initial Smoking Cessation Fee (Appendix E, Section 4.1) Eligible Models: CCM, FHG, FHN, GHC, HSO, PCN, RNPGA, SEAMO, SJHC Change: Annual $15 incentive payment on the normal visit fee. Context: Paid to physicians for dialogue with their enrolled patients who smoke. The physician may choose to refer to the "Smoking Cessation Guidelines for Physicians and Smoking Cessation Flow Sheet" to help facilitate and document dialogue, or the physician may choose a dialogue procedure consistent with the 5As model of the Clinical Tobacco Intervention program. Q041 is payable once per enrolled patient per 365 days.

Q042A Smoking Cessation Counselling Fee (Appendix E, Section 4.2) Eligible Models: CCM, FHG, FHN, GHC, HSO, PCN, RNPGA, SEAMO, SJHC Change: $1.50 additional fee. Context: Paid to physicians who provide follow-up smoking counselling sessions within 365 days of the service date of a valid Q041A. Physicians must submit the Q042A with an intermediate assessment (A007A) with the same service date. Physicians may refer to the "Smoking Cessation Guidelines for Physicians and Smoking Cessation Flow Sheet" or any other guidelines with similar elements to the above in order to support their counselling session. Q042A is payable twice per enrolled patient per 365 days following a valid Q041A.

Option for Payment to Individuals in FHNs (Appendix E, Section 10.6) Eligible Models: FHN Change: FHN template agreements will be amended to provide an option for capitation payments to individual physicians and payment of access bonus to the group. For further information, eligible physicians should contact their Ministry site team.

FHN Hard Cap - Insured Services to Non-Enrolled Patients Eligible Models: FHN, GHC, HSO, PCN Change: Maximum billings for insured services to non-enrolled patients will be increased as follows: 2005/06 - $45,000; 2006/07 - $47,500; 2007/08 - $48,500.

Q200A The Ministry has resolved the system issues that delayed the payment of the Per Patient Rostering Fee and other enrolment-related fees. The Ministry is mailing detailed information out to physicians, and copies of that information will be posted on the OMA website.

W010A Monthly Management Fee - Long-Term Care Monthly Management of a Nursing Home or Home for the Aged Patient is the provision by the most responsible physician (MRP) of routine medical care, management and supervision of a patient in a nursing home or home for the aged for one month. The service requires a minimum of two W-prefix assessments of the patient each month. Please note that the LTC capitation rates for PCN, FHN and HSO Agreements include the W010 code. For additional information, please refer to the Question & Answer segment in OHIP Bulletin 4435 posted on the Ministry website http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bulletin_4000_mn. html

Items Still in Progress: - LTC Capitation Rate (Appendix E, Section 12.1) - Colorectal Screening Bonus - Bonus Codes (Appendix E, Section 4.3) - Self-Help Manual (Appendix E, Section 5.1) - Rurality Gradient (Appendix E, Section 9.3) - FHN & FHG Evaluation (Appendix E, Section 10.3)

Resources for Members For additional information related to the OMA-MOHLTC Agreement, please visit: http://www.oma.org/Members/Economics/tracking.asp

For changes applicable to physicians in Primary Care models, including copies of Ministry communications to physicians, please visit: http://www.oma.org/PC/index.asp

To view the OMA Video Update on Primary Care, please visit: http://www.oma.org/PC/video/video.asp