Ontario docs ask government to fix OHIP billing

TORONTO – Ontario’s doctors are calling on the provincial government to modernize the province’s outdated OHIP billing system, using innovative solutions like AI to reduce red tape and ensure patients can access the care they need.

OHIP has failed to keep pace with modern medicine, and doctors say it consistently causes unnecessary delays and funding rejections that disrupt the care they provide to patients.

While the majority of OHIP claims are processed automatically, more than 1.16 million cases a year – or over 1,000 a week – are tied up in manual reviews, meaning physicians can wait months or even years to be reimbursed for the care they provide to patients.

This backlog affects care across the province, from lifesaving neurosurgeries to innovative reconstructive procedures like finger reattachments and breast cancer surgeries, and even the critical care of newborns who depend on urgent medical attention.

The administrative burden caused by these billing disputes is pulling doctors away from patients, and the OMA estimates that at least 58,000 additional patient visits could take place each year if these issues were resolved.

“Ontario’s doctors deliver world class care to their patients every day, but the OHIP system that supports that care is decades behind,” said OMA president Dr. Zainab Abdurrahman (pictured).

“Every hour a doctor spends dealing with rejected claims or billing disputes is an hour that could be spent caring for patients. Fixing these issues would free up tens of thousands of additional appointments for Ontarians.”

An OMA survey of more than 2,500 physicians found that 90 percent had claims rejected in 2024, while many reported spending significant amounts of time navigating billing disputes rather than seeing patients.

Doctors say the problem is particularly acute in surgical specialties, where a large proportion of billings are flagged for review even when procedures follow established standards of care.

To address the growing backlog and reduce unnecessary administrative work, Ontario’s doctors are recommending the province adopt targeted AI tools that can help modernize the claims review process.

AI could be used to identify patterns in billing decisions, help ensure consistent interpretation of billing rules across the province, and reduce the number of claims that are unnecessarily diverted into manual review.

“Doctors want to spend their time caring for patients, not navigating red tape,” said Dr. Abdurrahman.

“Innovative solutions, like AI tools that support faster and more consistent claims review, could dramatically reduce delays and make the system work better for everyone.”

Doctors say OHIP modernization would help take pressure off the health-care system and ensure physicians are funded promptly for medically necessary care, while reducing administrative burden that takes time away from patients and adds to physician burnout.

Reducing red tape that slows care
The OMA has launched a new provincewide advocacy campaign calling on the government to fix OHIP and reduce unnecessary red tape in the healthcare system.

In some surgical specialties, nearly all physicians have had claims flagged for manual review in the past year. When a significant portion of a doctor’s billings are delayed or rejected, it can create financial uncertainty for medical practices and even discourage physicians from performing certain critical procedures altogether.

The OMA has also proposed several measures to reduce administrative burden and improve how billing disputes are handled including:

• Create an independent OHIP ombuds office with clinical expertise to resolve billing disputes quickly and fairly.
• Set clear timelines for appeals, so doctors are not waiting months or years for decisions on rejected claims.
• Extend “good faith” OHIP coverage for newborns from 30 days to 90 days so doctors can care for eligible newborns who are not yet registered without forcing families to navigate paperwork after a child passes away.
• Ensure doctors are paid consistently for the same care across Ontario, so a procedure approved in one region is not rejected in another.
• Reduce unnecessary manual reviews of routine claims that create delays and administrative burden for physicians.

“These are solvable problems,” said Abdurrahman. “By listening to physicians who work within OHIP every day the government can reduce red tape, support innovation and ensure patients continue to receive high quality care.”