Reciprocal Billing – Claims for Out of Province Patients
Reciprocal billing agreements between the provinces (except for Quebec) allow physicians to submit claims to Manitoba Health for most services provided to out-of-province patients.
Generally, this includes services rendered in the ER, OPD or In-patient department of a hospital and private offices. Therefore, (except for patients from Quebec), you should submit your accounts for insured services provided to any Canadian resident to Manitoba Health for processing at Manitoba rates.
When checking the patient’s health care card, ensure that their coverage has not expired, as some provinces issue renewable rather than lifetime registration numbers.
Suppose a patient does not present a valid health care card. In that case, the patient should be considered uninsured and billed directly for all services at the rates recommended in the Association’s Billing for Uninsured Services guide (contact Doctors Manitoba for a copy of the Guide). The patient can then seek reimbursement from their private insurer or their home province’s insurance plan if they had bonafide coverage.
Patients from Quebec
Quebec does not participate in the interprovincial reciprocal billing agreement for physician services. Therefore, if you treat a patient from Quebec, your billing options are as follows:
- Bill the Quebec patient directly at your uninsured services rate (e.g., as you would for a U.S. patient). The patient can then seek reimbursement from the Quebec Health Plan (up to the rates payable for those services under the Quebec fee schedule) and/or private insurance, if applicable; or
- Bill the “The Regie de l’assurance maladie” (locate contact information at http://www.ramq.gouv.qc.ca/en/contact-us/citizens/pages/contact-us.aspx). You will be paid the applicable Quebec rates for the services rendered. You will also need to ensure that the patient’s Quebec health care card is valid.
Excluded Services — Directly Billed to the Patient
Provincial reciprocal billing agreements exclude certain medical services. These services should be billed directly to the non-resident at your uninsured services rate, even if he/she has a valid health card. The following are specified as excluded services by the reciprocal agreements:
- Surgery for alteration of appearance (cosmetic surgery);
- Sex-reassignment surgery;
- Surgery for reversal of sterilization;
- Routine periodic health examinations, including routine eye examinations;
- In-vitro fertilization, artificial insemination;
- Lithotripsy for gallbladder stones;
- The treatment of port-wine stains on other than the face or neck, regardless of the modality of treatment;
- Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy;
- Services to persons covered by other agencies: Armed Forces, Workers’ Compensation Board, Department of Veterans Affairs, Correctional Services of Canada (Federal penitentiaries);
- Services requested by a “third party”;
- Team conference(s);
- Genetic screening and other genetic investigations, including DNA probes;
- Procedures still in the experimental/developmental phase;
- Anaesthetic services and surgical assistant services associated with all of the foregoing.
The home province may or may not reimburse the patient for these services. The patient should make inquiries of their home province after direct payment to the physician.
Diagnostics Services in Hospital — Claimed through RHA
All provinces, including Quebec, participate in a separate reciprocal payment arrangement concerning Hospital services, including nursing care, accommodation in a ward, prescription drugs administered during hospitalization and diagnostic services. The in-hospital diagnostic services category includes certain professional services rendered by physicians (e.g., ECGs, Stress Tests, Lung Function Tests). Submit claims for services rendered to out-of-province patients (including patients from Quebec) in the hospital (ER, OPD or In-patient department) that provided the services and where the RHA will make the direct payment