When billing patients directly, physicians have been guided by various ethical and regulatory principles. This guideline attempts to integrate these existing principles in hopes of clarifying these matters for physicians. 

Definition: Uninsured services, for this policy's purpose, are:

  • Those that are not covered under Medicare or any other agency.
  • Services to patients not covered by Medicare
    1. non-residents of Canada,
    2. residents of Canada not covered under reciprocal billing arrangements,

Principles:

  • Consider, in determining professional fees, both the nature of the service provided and the ability of the patient to pay, and be prepared to discuss the fee with that patient.
  • Avoid promoting, as a member of the medical profession, any service (except your own) or product for personal gain.
  • The patient's best medical interest must always be foremost.

This policy provides general comment. In its specific application, the physician is accountable and must be able to justify his or her action in any direct billing.

Policy

  1. For any uninsured service, a physician may claim a professional fee.

  2. In all cases which are not purely elective, or where no other physician is reasonably available, the physician must provide care as clinically required, despite the fact that collection of fees may never be possible.

  3. The patients who may be directly billed must be informed and agree to the fee before provision of the service.
    • A physician's agent may give preliminary information to the patient about the billing policies in that practice, but it is the physician's responsibility to make any final decisions and be available to offer any explanation to the patient.

    • The physician providing the service must have a satisfactory system so that patients know they are free to ask questions of his/her about billing policies.

    • While a useful reminder, a general notice on the physician's door or elsewhere in the office is not sufficient by itself.

    • A referring physician should attempt to ensure that the patient is advised of the general billing policy of a proposed consultant for ensured and uninsured services. It then becomes the patient's responsibility to obtain further specific information from the consultant's office if necessary.

  4. Physicians may request, but they may not demand, payment in advance for professional services.

  5. In purely elective situations, a physician may refuse service in the absence of advance commitment for payment. This commitment could, for example, be a certified cheque to be cashed only after the service is provided. Legal remedies may be necessary where fees agreed to are not paid.

  6. Physicians may require deposits for prosthetic devices or any applicable facility fees.

  7. Telephone Advice:
    • Follow-up discussion concerning results of testing and treatment, and to clarify points of misunderstanding should be seen as included in the primary service benefit.

    • Any other service, when provided by telephone, may be billed directly to the patient.

    • A prudent physician will recognize the pitfalls that may be avoided by personal attendance on the patient.

Missed Appointments

Physicians may generally not bill for services not performed. Billing the patient for a missed appointment could constitute such. It is recognized that, under certain exceptions, physicians may bill patients for missed appointments when such charges had been discussed in advance with the patient and the patient has agreed. Council chooses not to identify what might constitute a suitable exception and feels that, in the event of a complaint being lodged with the College, the onus would be on the physician to justify the billing.

It is hoped that simply declaring a policy of billing for missed appointments will lead to a greatly reduced frequency of patients failing to attend as scheduled. All patients must be aware of this policy at the time of booking an appointment.

This principle recognizes the value of the therapeutic contract between physicians and patients. This contract can be damaged by patients missing appointments without sufficient reason and without as much notice as possible (at least 24 hours). At the same time, physicians have an obligation to respect their patients' time and should ensure that they are seen on a timely basis. This is the quid pro quo.

In order for a physician to invoice a patient for a missed appointment, the following requirements are necessary:

i. There must be evidence that the patient was informed of the physician's policy on missed appointments.

ii. The patient has failed to cancel the appointment more than 24 hours in advance.

iii. The physician must have a 24 hour messaging service (answering service, answering machine, voice-mail) by which the patient can advise of their inability to keep their appointment. Such a service must be accessible both during and after regular office hours.

iv. The physician must have been available to the patient at the intended appointment time.

v. The charges must reasonably reflect the actual costs incurred.

It is improper to refuse subsequent care in the presence of an outstanding invoice. However, recurrent failure to keep appointments may be grounds for termination of the doctor/patient relationship.

The Use of Deposits

In certain situations, physicians may require deposits for devices, supplies, and the like. The circumstances for forfeiture of such deposits must be made clear to the patients.

Annual Administration Fee

It is acceptable for a physician to bill a patient on an annual basis for uninsured services, subject to the following conditions:

  • The contract between physician and patient must cover a period of not less than three months nor more than one full year.

  • The contract must accurately and clearly show in writing the services that are covered by the annual composite fee and those that are not included. Patients have the right to ask their doctor about any charge they do not understand.

  • The contract must also show the fees for each uninsured service if paid for on an individual basis.

  • The contract and fees may vary from physician to physician and within group practices according to the services provided. Physician may be guided by the Physician Guide to Direct Billing from the New Brunswick Medical Society.

  • A copy of these rules must be given to the patient, and the patient must indicate acceptance of this form of paying for uninsured services before being billed the annual fee.

  • Patients must retain their choice of paying the annual fee or being billed on an individual item by item basis.

  • Acceptance or continuation of care by a physician of an individual patient cannot be conditional on the patient agreeing to the annual administrative fee.

  • Under College regulations, it is improper to charge a patient simply for being available for telephone advice or any other service.

Transfer of Medical Information

The timely and efficient transfer of medical information can be essential to on-going health care. Thus the priority, when exchange of information is requested, should be expediting such communication.

In most circumstances, information will be transferred at the request of the patient. Under such circumstances it is reasonable for the physician to invoice the patient directly for the cost of doing so. At times, the patient may insist on transfer of a complete medical chart. This is rarely, if ever, necessary. This fact should be clearly explained to the patient.

In other circumstances, the request for information may come directly from another physician. Where the information requested is specific, such as a particular report, such information should be transferred as a professional courtesy without charge. In very rare circumstances, it will be the new physician, as opposed to the patient, who requests transfer of the entire record. In such circumstances, the requesting physician should arrange for prior authorization from the patient to show both authority to release information as well as acceptance of responsibility for payment. Absent such a declaration, it is open to the physician providing the information to invoice the requesting physician directly.

Physician Dispensing/Supplying

When a physician supplies a product or service other than medical care, directly or indirectly, to a patient, and is compensated for same, there is the potential for an ethical conflict.

As noted above, the Code of Ethics precludes "personal gain" as the motive for promoting a product or service.

Thus, it will be presumed that a physician is motivated by personal gain in ordering or dispensing unless this presumption is rebutted by various mitigating factors:

  1. The product or service is provided at or near cost by the physician.

  2. The product or service is otherwise unavailable, and continues to be so.

  3. The product or service is otherwise available, but only at a significantly greater cost or inconvenience to the patient.

  4. The provision of the product or service requires a particular expertise which is unavailable except through the physician.

In any case, the patient must be made aware of all the alternatives to the provision of the service or product by the physician, such that an informed choice can be made. Furthermore, in all cases, the physician must be able to demonstrate, if challenged, that any conduct in recommending, ordering, or prescribing a particular product or service was unequivocally in the patient's best interests.

Adopted 11/99; affirmed 11/13