Dr. Ronen Avram wanted to find a better way to surgically reconstruct breasts for women who had mastectomies following a devastating cancer diagnosis.
The Hamilton surgeon, together with his surgical colleague Dr. Chris Coroneos, borrowed a technique commonly used by orthopedic surgeons and tweaked it for breast reconstruction. The goal was to release muscles in the patient’s chest to make the breast implant move more naturally under the skin.
The pair, who work at Juravinski Hospital, a regional cancer centre in Hamilton, say they fought for three years to have the Ministry of Health accept a billing code for the adapted technique so they could be compensated for their work.
Now, one year later, and even with a letter of approval from the ministry, the surgeons say they continue to face rejections when they submit the code to OHIP. Though they can appeal, the doctors say the process — for this code and for other rejected complex procedures — is an escalating problem that’s taking up more and more of their time.
“We aren’t doing research. We aren’t calling patients. We aren’t advancing patient care,” said Avram, a reconstructive plastic surgeon at Hamilton Health Sciences. “We’re just devoting time to arguing with the Ministry of Health. That’s not the way surgeons should be spending their time.”
For Avram and Coroneos, frustration with the OHIP system has mounted so high it’s pushing them out of Ontario’s publicly funded health system and into private practice. The pair has recently opened an independent surgical centre in Burlington, where they offer cosmetic procedures, including body contouring and cosmetic breast procedures, alongside some OHIP-covered work, such as skin cancer removal.
“The administrative burden of my job goes far beyond what it’s worth; it’s the main reason people get sick of the system,” said Coroneos, also a reconstructive plastic surgeon at Hamilton Health Sciences.
The Ontario Medical Association says doctors across the province are facing challenges with their OHIP billings, a problem that has ramped up in recent years. It’s warning that doctors are forced to wait months for delayed payments and that dealing with rejected or unresolved claims has become so burdensome it’s taking time away from patients.
Last month, the physician advocacy organization called on the province to revamp the OHIP billing system to curb the number of rejections to ensure doctors get paid.
Many surgeons, especially those who work at large teaching hospitals, say the outdated billing system doesn’t account for newer or more complex surgeries, which leads to delayed or denied payment. The result is that some surgeons have chosen to no longer offer certain procedures, while others have left the province.
What are plastic surgeons facing?
Coroneos said Ontario’s plastic surgeons have other options because their specialty allows them to easily move into private practice.
“They are far more likely to stop offering procedures covered by the Ministry of Health and work in the cosmetic realm,” Coroneos said. “This does constitute leaving OHIP.”
Plastic surgeons who work in a private practice not only get a boost to their income but will have a better work-life balance while dealing with fewer administrative hurdles, Coroneos said.
Both he and Avram say the next generation of plastic surgeons getting trained at their hospital have seen first-hand the challenges that come with working within the OHIP system and the relative ease of working in private practice. They worry that younger doctors in their specialty will avoid working in academic teaching hospitals unless things change.
“Our trainees are less and less interested in working in these centres,” Avram said.
Is the province making changes to the OHIP system?
OMA president Dr. Zainab Abdurrahman said the organization has not seen meaningful progress on the OHIP billing issue since raising it last month at Queen’s Park.
“Surgeons continue to face rejected claims and delays, which is delaying their ability to provide care efficiently,” she said. Among its asks to the province, the OMA wants an update to OHIP’s schedule of benefits to better reflect medical advances; faster timelines and more transparency in the review process; and a new OHIP Ombudsman who can intervene on billing issues.
A spokesperson for Health Minister Sylvia Jones said in a statement that Ontario’s Medical Claims Payment System processes more than 200 million claims every year, with 99 per cent paid automatically and less than one per cent sent for manual review.
Manual review is triggered when a claim cannot be processed through OHIP’s automated system. Instead, it is sent to the Health Ministry for assessment and doctors are required to provide detailed documentation as proof they provided the service. The OMA says this process leads to delays and decreases in payment and that some billing claims may never be paid.
Ema Popovic, Jones’s spokesperson, said more than 95 per cent of claims sent to manual review are resolved within 30 days and that, in general, two-thirds are labelled as Complex Surgical Claims and which involve multiple procedures. She said the ministry’s three-tier manual review process is appropriate, that a physician will conduct the final review and that the appeal process is open to doctors.
The Health Ministry did not answer follow-up questions on the OHIP billing system. Popovic instead reiterated that it was “disappointing that the OMA is choosing to focus on 0.58 per cent of claims.”
Abdurrahman said that while it’s true that only a fraction of claims go to manual review, the OMA projects about 1,000 cases a week trigger the process and take more than 30 days to resolve. She said these cases are often concentrated among certain surgical specialties and surgeons.
“Though the (ministry) might say, this problem affects a fraction of all OHIP billings, it could be a huge proportion for someone who does complex surgeries, who has all this extra training to provide this level of care,” she said. “(It) sets them up to not want to continue doing all this innovative, complex surgery that we know our patients need.”
Coroneos, who specializes in microsurgery and breast reconstruction, said the current OHIP system lacks the capacity and flexibility to account for new procedures, which stifles innovation in his field.
In his hospital practice, Coroneos said about one-third of cases he sends to manual review take between six and 11 months to get resolved. These include breast reconstructions, surgeries to repair or salvage limbs and on-call emergency trauma cases.
Avram said compensation worries do not influence what procedures he and Coroneos offer in hospital, noting they perform the best available option for patients even if they know they will not get compensated quickly or fully for their work. More than the chance of not getting paid, Avram said it’s the drawn-out process that is most wearing because it’s not transparent or mindful of the surgeon’s role.
“There’s a lack of respect,” he said. “When you get email after email like that, it becomes insufferable.”
Both doctors say delayed or denied compensation — and the headaches that go along with the process — is dissuading trainees from practising in hospitals. And that, Coroneos said, will have an impact on patients.
“Wait lists are already long. They will only get longer.”
