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POLICY: Uninsured Services

1. Preamble

The Canada Health Act and The Saskatchewan Medical Care Insurance Act provide the legislative framework for the payment of insured health services in Saskatchewan.  This policy seeks to clarify how physicians can charge patients for services that are not covered within the public health system.  Patients may request physician services which are not paid by the Saskatchewan Medical Services Branch (“MSB”) in accordance with the Payment Schedule for Insured Services Provided by a Physician (“Payment Schedule”).  Physicians are entitled to charge patients for these uninsured services, but are expected to do so in accordance with this policy.

This policy sets out the College’s expectations of physicians in relation to billing for uninsured services.  This policy must be read in conjunction with CPSS regulatory bylaw 9.1 and the CPSS guideline on Conflict of Interest.  As payment for uninsured services is not subject to the same external monitoring system as insured services, patients paying privately for uninsured services rely on the honesty and integrity of physicians to ensure that their needs and interests are prioritized. 

2. Definitions

For the purpose of this policy, the following definitions apply:

Insured services include services listed in The Saskatchewan Medical Care Insurance Act and the Payment Schedule that are publicly funded by MSB, provided that the service is medically required and provided to an insured person by a physician.

Uninsured services include:

1. 1) professional services provided by physicians that are not publicly funded by MSB.Examples include sick notes for employment, copy and transfer of medical records, prescription refills over the phone, the completion of insurance and/or medical forms, certain telemedicine services, and a number of medical procedures including cosmetic procedures;
2. 2) medically required services provided to persons who are not insured by the Saskatchewan public health care system.Examples include patients who do not meet the eligibility requirements pursuant to the Canada Health Act, patients who are privately insured, and patients who have excluded themselves from the Saskatchewan public health care system; and
3. 3) medically required services that are available on a private pay basis.Examples include certain diagnostic imaging procedures including those provided pursuant to The Patient Choice Medical Imaging Act, and certain surgeries that are medically indicated but have been designated as uninsured services in The Saskatchewan Medical Care Insurance Act and The Medical Care Insurance Beneficiary and Administration Regulations.

Professional services include both medical and non-medical services.

Block fees are fixed fees for all designated uninsured services provided during a specified time period.  At the time of payment it will not be possible for the patient to know how many, if any, services will be required.

For the purpose of this policy, the word “physician” means any individual licensed by the CPSS, including individuals licensed on the educational register.

3. Guiding principles

Physicians who choose to provide uninsured services and to bill patients for those uninsured services are governed by the following guiding principles:

1. 1) They must ensure they do so in a manner that is in keeping with their professional, ethical and legal obligations.  Reference should be made to the Code of Ethics adopted by the College within Regulatory Bylaw 7.1.
2. 2) They must not exploit their patients’ trust for their own personal advantage, financial or otherwise.
3. 3) They must consider the availability of publicly-funded services before offering a private pay option.
4. 4) They must adhere to their fiduciary responsibility when providing and billing for uninsured services.
5. 5) They must ensure compliance with the College policies “Performing Office-based Non-insured Procedures” and “Complementary and Alternative Therapies.”

4. Expectations of physicians providing uninsured services

1) Physicians cannot charge an insured person more than the insured rate for any medically required service that is covered by MSB unless a) the service is designated an uninsured service pursuant to The Saskatchewan Medical Care Insurance Act or The Medical Care Insurance Beneficiary and Administration Regulations, or b) the physician has opted to practise entirely outside the plan and has complied with the requirements of the Payment Schedule in order to do so. 

2) Amounts charged for uninsured professional services (including block fees) must be reasonable.  In determining the appropriate fee, physicians are directed to the Saskatchewan Medical Association Fee Guide (uninsured services) for guidance.  Physicians should take into consideration their professional and administrative costs as well as the patient’s ability to pay.  If asked, a physician must be able to account for the fee charged for the service.

3) The patient must be informed of the fee in advance of providing the uninsured service. While office staff may provide preliminary information to a patient about billing policies in the practice, the physician remains responsible for the final decision and explanation to the patient when the patient disputes the fee or requests clarification.

4)  In situations such as a medical emergency, physicians are expected to provide medically required services before and irrespective of determining whether a patient is insured.

5)  Physicians are not permitted to charge a fee in exchange for a promise or provision of preferential access to services. 

6) If a physician offers a block fee option, the physician must:

a. allow the patient the choice of paying the block fee or for each professional service individually as provided;
b. provide the patient with the block fee option in writing;
c. ensure the patient is given sufficient information to make an informed choice including:

i)  a list of fees that will be charged individually for each professional service if the patient declines the block fee option; and

ii)  a copy of this policy.

7)  If a physician offers a block fee option, the physician must not:

a. refuse to provide an insured professional service because a patient has not paid a block fee for uninsured services;
b. include in a block fee any service for which the physician is compensated through any other means, including any charge for a professional service which is included as part of an insured professional service; and
c. promise or provide preferential services to a patient who paid a block fee.
 

ACKNOWLEDGEMENTS

The College gratefully acknowledges the College of Physicians and Surgeons of Alberta and the College of Physicians and Surgeons of Ontario for permitting their documents ‘Charging for Uninsured Professional Services’ and ‘Uninsured Services:  Billing and Block Fees’, respectively, to be adapted in preparing this policy. 

OTHER RESOURCES

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 9.1
College of Physicians and Surgeons of Saskatchewan – Guideline – Conflict of Interest
College of Physicians and Surgeons of Saskatchewan – Policy – Sale of Products by Physicians
College of Physicians and Surgeons of Saskatchewan – Policy -- Complementary and Alternative Therapies
College of Physicians and Surgeons of Saskatchewan – Policy – Performing Office-based Non-insured Procedures
College of Physicians and Surgeons of Saskatchewan – Policy – The Practice of Telemedicine