After Hours Premiums
The After Hours Premiums tariffs (5555, 5553 and 5550) and applicable rules are listed on pages B‑1 and B‑2 of the Physician’s Manual.
An After Hours Premium (either 50% or 75%, depending on the time of day/day of the week the service is provided) is payable in addition to the fee for a medical service if:
- the medical service commences during the hours set out in the After Hours Premium tariffs, and
- the medical service provided is urgent/emergent or noted in the Physicians Manual section for services deemed urgent or emergent.
Note: If the visit occurs after hours and is not urgent or emergent, it may still qualify for the Primary Care Extended Hours Premium (learn more it here).
What is Urgent/Emergent?
The Physician’s Manual does not provide a specific definition ofurgent/emergent. Physicians must therefore use their clinical judgment when determining whether a service qualifies.
Urgency is determined by the patient’s medical condition, risk of deterioration, and the need for timely assessment or treatment. Urgency is not driven by patient convenience, scheduling preferences, or the fact that the service simply occurred after regular office hours.
The guidelines used for classifying the acuity of a patient’s condition are nationally recognized, internationally accepted, and endorsed by the Canadian Association of Emergency Physicians. An after-hours premium may be appropriate if the patient’s condition falls within CTAS Level I (Resuscitation), Level II (Emergent), Level III (Urgent) or less commonly, Level IV (Less Urgent/Semi-Urgent).
Another factor in determining whether a service qualifies asurgent/emergent particularly for house calls and virtual services, is when the patient’s call was received and when the service was rendered. The greater the lapse of time between these two events, the less likely the service could be consideredurgent/emergent.
Where can after hours premiums apply?
While it’s less common for after-hours premiums to apply to visits delivered outside of an acute care facility, the rules permit this in certain situations, including:
- In a physician’s office: provided the physician’s office does not maintain regular hours of operation that fall within the periods of time specified in the After Hours Premium tariffs, and
- In a patients’ home: even when those services are provided during the regular operating hours of a business dedicated to providing house call services.
- After Hours Premiums apply to communication claims under Tariff 8000, 8001, 8005, 8355, and 8356 where the communication occurs during an eligible After Hours Premium period and is of an urgent/emergent nature. After hours premiums for virtual visits should consider the same factors.
Physicians who provide on-call coverage of the emergency/out-patient departments of rural hospitals can claim After Hours Premiums where fee-for-service billings are permitted, and the urgent/emergent service is provided during an after-hours premium period.
How are premiums calculated?
After Hours Premiums are calculated based on the total fee for all services rendered during the after-hours period.
Documentation Practices
For claims that include an After Hours Premium, physicians should ensure both the claim and the medical record clearly support the urgent/emergent nature of the service.
The Physician’s Manual requires physicians to include the wordsurgent/emergent, to explain the nature of the service; and
- if the ICD code included on the claim does not clearly demonstrate the urgent/emergent nature of the service, include a brief comment explaining why the service was urgent/emergent; and
- ensure the claim and medical record clearly describe the patient’s clinical condition, the need for timely assessment or treatment, and why the service could not reasonably wait until regular clinic hours.
If Manitoba Health determines that the documentation does not adequately support the urgent/emergent nature of the service, the claim may be held, and additional information may be requested.