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POLICY: Uninsured Services

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.  The College recognizes that physicians may also provide services which are not paid by the Saskatchewan Medical Services Branch (“MSB”) or the Saskatchewan public health system.  Physicians are entitled to charge patients or third parties for these uninsured services, and the same ethical obligations apply when billing for insured or uninsured services.  They are expected to demonstrate integrity and transparency and ensure the patient or third party is aware of the fees prior to providing the service.  

This policy sets out the College’s expectations of physicians in relation to the provision of and billing for services that are not covered within the public health system.
 

POLICY

 1. Definitions

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

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 example, a block fee may cover all uninsured professional services such as providing medical notes for an employer, copy/transfer of medical records, and completing forms within an identified block of time.  A block fee may also be charged for a series of medical professional services such as cosmetic procedures.

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

Patient includes the individual receiving the service and where applicable, the patient’s legal guardian or substitute decision maker.

Physician includes any individual licensed by the CPSS, including individuals on the educational register, but excluding podiatric surgeons and physician assistants.

Professional services include both medical (such as providing cosmetic treatments or other uninsured medical procedures) and non-medical (such as completing forms) services.

Third party is a recipient of an uninsured service who is not a patient.  An example is an insurance company that retains the physician to conduct a non-treating medical examination.  

Uninsured services include: 

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, the completion of third party forms, conducting non-treating medical examinations, conducting medico-legal document reviews, certain virtual care services, and a number of medical procedures including cosmetic procedures;  
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; 
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 Medical Imaging Facilities Licensing Regulations, and certain services  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; and
4. medically required services that are provided by physicians who have opted to practise entirely outside the Payment Schedule and who have complied with the requirements of The Saskatchewan Medical Care Insurance Act (section 24) and  Payment Schedule in order to do so.

2. 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. 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, an particularly paragraph 26:

“Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees.”

2. They must not exploit their patients’ trust for their own personal advantage, financial or otherwise.
3. They must consider the availability of publicly-funded services before offering a private pay option. 
4. They must adhere to their fiduciary responsibility when providing and billing for uninsured services to patients. 
5. They must ensure compliance with the College policies “Performing Office-based Non-insured Procedures” and “Complementary and Alternative Therapies” as well as CPSS Regulatory Bylaw 9.1 – Conflict of Interest and guideline “Conflict of Interest.”

3. Expectations of physicians providing uninsured services 

1. The patient or third party must be informed of the fee in advance of providing the uninsured service, whether it is a professional service or medically required service. While office staff may provide preliminary information to a patient or third party about billing policies in the practice and/or general information regarding fees may be posted on the website or in the physician’s office, the physician remains responsible for obtaining the patient’s or third party’s final consent and providing explanations to the patient or third party when they dispute the fee or request clarification.  While physicians are strongly encouraged to provide a written estimate of the costs to the patient or third party in advance, this is not a substitute for a verbal discussion between the physician and the patient or third party.  The most responsible physician is at all times responsible to obtain consent and explain the fees.  Learners on the educational register should not be expected to perform these tasks.   
2. In addition, the most responsible physician is responsible to inform the patient of any comparable publicly-funded services, where applicable.
3. 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 for 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 and must provide a detailed invoice when requested.
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) ensure that the amount charged for a block fee is reasonable in relation to the services and the period of time covered by the block fee;
(b) advise the patient of the timeframe for the block fee before accepting payment of the block fee;
(c) allow the patient the choice of paying the block fee or for each professional service individually as provided if applicable;
(d) ensure the patient is given sufficient information to make an informed choice including:

(i) a list of services that are included in the block fee including how much each service would cost if paid for on a fee-for-service basis; and 
(ii) advice that this policy is available on the CPSS website;

(e) provide the patient with the block fee option in writing using plain language.  Care must be taken to avoid language that could be perceived as suggesting that services or quality of care may be limited if the patient opts not to pay the block fee.  

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

OTHER RESOURCES

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 7.1, The Code of Ethics

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 7.2, Code of Conduct

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 9.1, Conflict of Interest

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 – Virtual Care

College of Physicians and Surgeons of Saskatchewan – Policy – Completion of Third Party Forms and Certification of Work Absence / Accommodation due to Illness or Injury

College of Physicians and Surgeons of Saskatchewan – Policy – Medical Examinations by Non-Treating Physicians (NTMEs)

Saskatchewan Medical Association – Fee Guide for Uninsured Services