Complaint Underscores Risks of Billing Outside OHIP: Physicians Take Note
Recent developments in Ontario’s health care system underscore the increasing complexity and risk associated with billing outside of the Ontario Health Insurance Plan (OHIP). In June 2025, the Ontario Health Coalition (OHC) filed formal complaints on behalf of 50 patients who were charged out-of-pocket fees for services that they submit should have been publicly insured. The open letters to the Federal and Provincial Ministers of Health can be found here and here. The OHC’s most recent response is available here.
The patient circumstances that are the subject of the OHC’s complaints—primarily involving cataract surgeries performed in private clinics—have generated public concern and media attention. Many patients, particularly seniors on fixed incomes, reported feeling pressured into paying fees ranging from several hundred to several thousand dollars to access timely care or "premium" service options.
While these concerns have centered around patient access and equity, the implications for physicians are equally significant. Any regulated health professional who bills under OHIP must take extreme care when engaging in or endorsing any form of private billing. The legal framework governing such practices is nuanced, and even an inadvertent charge or an insured service can result in serious consequences.
Understanding the Regulatory Landscape
The provision of publicly insured services in Ontario is governed by the Health Insurance Act, the Commitment to the Future of Medicare Act (CFMA), as well as the federal Canada Health Act. The Ontario statutes prohibit charging patients for any component of a service that is insured under OHIP, while the federal legislation permits the federal government to penalize provincial governments for permitting private payments for insured services. This includes not only the service itself but also associated assessments, diagnostics, facility fees, and materials that are deemed medically necessary. Physicians are required to deliver these services without charging patients directly—regardless of whether the service is performed in their office, an independent health facility or integrated community health services centre, or a private surgical clinic.
While some exceptions exist for uninsured services or patient-requested enhancements, the rules governing these distinctions are highly specific and complex. In several of the recent complaints, patients alleged they were misled into believing they had no access to publicly funded care without paying out-of-pocket—an issue that may constitute a breach of both provincial and federal law, and potentially the policies of the College of Physicians and Surgeons of Ontario (the "CPSO").
In many of the reported cases, it was not the fee or the service itself that was offensive, but rather the information regarding the services and how it was communicated. This is a significant area of risk for physicians who charge any fees to patients, and shows how important it is that information regarding services and fees be accurately and sensitively communicated to patients. It is particularly risky if patients be led to believe that purchase of an uninsured, paid service is necessary in order to access timely care, particularly when a publicly insured alternative is available. This may occur in the context of “upselling,” such as encouraging patients to purchase premium lenses or additional diagnostic tests by emphasizing long wait times or quality differences. While offering uninsured enhancements is not inappropriate, and indeed may be part of an appropriate informed consent discussion, failure to clearly distinguish between insured and uninsured services—and to ensure that patients understand they have a no-cost, medically equivalent option—may violate both the spirit and the letter of the law.
The issue is not simply what is goods or services are charged to patients, but how that information is communicated. If patients consent to private payment based on incomplete or misleading information, regulators or Ministry investigators may view that consent as invalid. In such cases, the physician may be found to have facilitated or participated in improper billing, potentially resulting in a repayment order and/or a CPSO complaint or investigation. This is why full transparency, documented informed financial consent, and strict adherence to billing guidelines are essential.
Protecting Your Practice Through Proactive Oversight
In a landscape where public and private funding models increasingly intersect, it is essential that physicians understand the limits of what can and cannot be billed outside of OHIP.
Common areas of risk include:
Charging for expedited access to an insured service
Requiring payment for diagnostic tests associated with an OHIP-covered procedure
Offering bundled packages that include both insured and uninsured components without clear patient consent or distinction
Misrepresenting wait times to encourage private payment
While many physicians rely on clinic administrators or billing staff to manage these elements, it is important to recognize that the responsibility for compliance ultimately rests with the provider. Regulatory colleges and government authorities may hold physicians accountable even if they were not directly involved in fee collection.
Given the complexity of this regulatory environment, physicians are strongly advised to seek expert guidance before implementing or participating in any model involving patient charges for services related to OHIP-insured care. This includes reviewing:
Billing structures and fee schedules
Consent forms and patient communication protocols
Clinic policies regarding uninsured services
As Ontario continues to expand the role of private clinics in delivering publicly funded services, the risk to physicians continues to grow. If you or your organization is involved in a private or hybrid practice model, make it a priority to review your billing processes. If you have questions or need support navigating billing regulations, our team is here to help.
