We’re asking government to:
Ensure there are reasonable timelines for appeal of rejected claims
Establish an ombuds office staffed with those who have clinical expertise to help resolve funding disputes in a timely and informed manner
Create a committee of the OMA and government to review innovative procedures and ensure they are funded
Make certain the system can process funding as outlined in the Physician Services Agreement. When errors are made, they should be accompanied and complemented with appropriate financial considerations to ensure clinical operations are not compromised
There are four main problems with OHIP:
Rejected claims
Each year, OHIP processes about 200 million claims, and while the majority of these are approved without issue, about 1.16 million are rejected annually. The majority of these are settled in about 30 days. However, more than 58,000 patient services are rejected each year through OHIP and take more than 30 days to resolve. Many of these cases represent some of the most complex procedures, which means OHIP is rejecting upwards of 1,000 cases a week.
Lack of a valid card
For many reasons, people may not have a valid OHIP card, even though they are eligible as an official Ontario resident. They may not have renewed it, or they may not have a permanent address.
While these situations are concerning, more troubling is a situation where newborn babies with pre-assigned health numbers that expire after 30 days are left without coverage because of delays or errors in the registration process. In all these cases, doctors aren’t receiving funding for the care they provide.
Failure to keep pace with innovation
Innovation in health care helps reduce the length of hospital stays — or avoid admission entirely. It also lowers system costs and improves patient outcomes and experience. But the process for adding new billing codes to keep pace with new treatments is painstakingly slow. Advances in care from a decade ago, in areas such as cardiac surgery, have yet to be recognized in the system. We need to ensure funding is keeping up with the most up-to-date care.
Errors in funding
Ontario’s technology system for funding physician care is not easily updated. In the past year, there have been multiple incidents of overpayment, underpayment and missed payments. The system is slow and lacks agility to keep up with the changing and evolving demands of the province’s health-care needs.
Rejected claims
Each year, OHIP processes about 200 million claims, and while the majority of these are approved without issue, about 1.16 million are rejected annually. The majority of these are settled in about 30 days. However, 58,000 of these take considerably longer to resolve — from months to several years. Many of these cases represent some of the most complex procedures, which means OHIP is rejecting upwards of 1,000 cases a week.
Lack of a valid card
For many reasons, people may not have a valid OHIP card, even though they are eligible as an official Ontario resident. They may not have renewed it, or they may not have a permanent address.
While these situations are concerning, more troubling is a situation where newborn babies with pre-assigned health numbers that expire after 30 days are left without coverage because of delays or errors in the registration process. In all these cases, doctors aren’t receiving funding for the care they provide.
Failure to keep pace with innovation
Innovation in health care helps reduce the length of hospital stays — or avoid admission entirely. It also lowers system costs and improves patient outcomes and experience. But the process for adding new billing codes to keep pace with new treatments is painstakingly slow. Advances in care from a decade ago, in areas such as cardiac surgery, have yet to be recognized in the system. We need to ensure funding is keeping up with the most up-to-date care.
Errors in funding
Ontario’s technology system for funding physician care is not easily updated. In the past year, there have been multiple incidents of overpayment, underpayment and missed payments. The system is slow and lacks agility to keep up with the changing and evolving demands of the province’s health-care needs.
Why it matters
These problems are widespread — a January 2025 OMA survey with more than 2,500 physician responses showed that 90 per cent of them had OHIP claims for payment rejected in 2024.
47%
felt that more than half their claims were rejected without reasonable cause
66%
said administrative time spent on rejected billings reduced time spent on direct patient care
48%
are less willing to perform certain procedures due to billing rejections
Based on the survey results, we estimate that an additional
57,528 Ontario patients
could have been seen in 2024 if rejected claims were not an issue.
Doctors going unpaid as OHIP rejects 1M-plus claims a year
Fix needed now for taxpayer-funded health plan
Ontario doctors are providing urgent health-care procedures, without pay, to accident victims, newborns, unhoused people and other vulnerable patients, as an antiquated and flawed OHIP billing system rejects more than one million claims a year.
In one case, a surgeon spent 15 hours in 2022 reattaching four fingers to a farmer’s hand after it was crushed in an equipment accident. After OHIP rejections and multiple appeals for review and common sense, it took three years for the surgeon to be compensated for this critical work that meant the difference between a patient resuming their work or suffering through a life-changing injury.
“This was difficult work done under the operating room microscope overnight,” recalls Dr. Braden Gammon, director of the University of Ottawa Hand Fellowship Program.
“Afterwards, I submitted my bill to the government and was paid $0. Three years later, this gentleman has successfully returned to farming with all four of his fingers intact, and I still had been paid $0.”
Dr. Braden Gammon
After his claim was rejected by the Ministry of Health, Dr. Gammon had to relentlessly advocate for payment through multiple emails and phone calls, and five resubmissions. He was not paid anything until June 2025.
Ontario doctors are providing urgent health-care procedures, without pay, to accident victims, newborns, unhoused people and other vulnerable patients, as an antiquated and flawed OHIP billing system rejects more than one million claims a year.
In one case, a surgeon spent 15 hours in 2022 reattaching four fingers to a farmer’s hand after it was crushed in an equipment accident. After OHIP rejections and multiple appeals for review and common sense, it took three years for the surgeon to be compensated for this critical work that meant the difference between a patient resuming their work or suffering through a life-changing injury.
“This was difficult work done under the operating room microscope overnight,” recalls Dr. Braden Gammon, director of the University of Ottawa Hand Fellowship Program.
“Afterwards, I submitted my bill to the government and was paid $0. Three years later, this gentleman has successfully returned to farming with all four of his fingers intact, and I still had been paid $0.”
Dr. Braden Gammon
After his claim was rejected by the Ministry of Health, Dr. Gammon had to relentlessly advocate for payment through multiple emails and phone calls, and five resubmissions. He was not paid anything until June 2025.
Pediatricians are also routinely denied claims for care provided to newborns when there has been a delay in registering the baby’s official health card at Service Ontario.
“It makes me feel very frustrated,” says Dr. Jane Healey, a pediatrician based in Mississauga, Ont., and the OMA's section chair of pediatrics.
“This problem doesn’t exist in every province. Ontario has chosen this very cumbersome process with multiple failure points that are completely outside the physician’s control.”
Dr. Jane Healey
For example, during a postal strike one year, 56 of Dr. Healey’s claims for newborn care were rejected because the infants’ registration forms did not reach the OHIP offices, and then expired.
When OHIP rejects newborn claims, the government expects doctors to track down parents and direct them to Service Ontario to correct the health-card registration. This is a time-consuming inconvenience for doctors and new parents.
Doctors who treat unhoused patients also go unpaid when the person’s health card number is ruled invalid because they’ve moved shelters and have not updated the address on their health card.
“About a third of our patients are homeless,” says Dr. Chris Cavacuiti, an addiction doctor at trueNorth Medical Centre.
“(Unhoused patients) really, really struggle to maintain valid health coverage because health coverage is tied to having an address.”
Dr. Chris Cavacuiti
Dr. Cavacuiti says homeless patients are forced to go through a three-to-six-month process to update their health cards.
“During that entire period, their coverage is invalid. Many patients fall through the cracks and never finish the renewal process,” he says.
“Even for those who do, coverage is rarely retroactive — even when there’s clear proof they were living in Ontario. That means physicians aren’t paid for months of care. It’s outrageous.”
Red tape can lead to payment delays, denials
To receive payment for their services, Ontario physicians must first submit a claim to OHIP. The taxpayer-funded health plan is then responsible for reviewing doctors’ claims and making decisions on what care is funded. If a claim doesn’t conform to OHIP’s often-complex rules, it can be denied.
Most appeals are resolved in about 30 days, but about 58,000 claims can take months to several years to yield payment for doctors. That’s about 1,000 cases a week.
These figures, however, hide the many cases where doctors don’t submit claims for their work in the first place because the added bureaucracy takes precious time away from patient care.
Dr. Mojola Omole, a breast surgical oncologist and general surgeon at Toronto’s Scarborough Health Network, often has claims rejected in cases involving plastic surgery and breast reconstruction, and when a patient receives more than one procedure.
Challenging these OHIP decisions is time-consuming — and often unsuccessful.
“Instead of me spending hours trying to talk to someone at the ministry, I would just submit something that I know will go through, even though it does not encompass all the work that I’ve done.”
Dr. Mojola Omole
These are just a few examples that illustrate a health insurance plan that is out of date and fails to recognize the complexity of many medical procedures and surgeries. Ontario’s doctors are calling for an urgent overhaul.
Dr. Warren Latham, chief of orthopedics at Scarborough Health, says complex surgeries require him to submit a claim to OHIP encompassing multiple parts. This triggers an automatic review by non-specialists, which can take six to nine months. Most often, several parts of his claim are ultimately rejected.
“I’m not being paid adequately or appropriately for these complex surgeries,” he says. “This certainly makes me reconsider whether or not these surgeries are something that I should be offering in my practice.”
Patients and physicians need OHIP to work. But it is antiquated and flawed and requires an immediate fix. You deserve better.
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