Dr. Jane Healey, a Toronto-area pediatrician, is calling attention to systemic issues within Ontario’s health insurance billing system after spending 10 days caring for a dying newborn without receiving any compensation. When the Ontario Health Insurance Plan (OHIP) rejected her claim, Healey faced a heartbreaking decision: either forgo payment or ask the baby’s grieving parents to visit Service Ontario. Choosing compassion over bureaucracy, she decided not to burden the family, absorbing the financial loss herself.
Healey, who also serves as the Ontario Medical Association’s (OMA) section chair for pediatrics, says her experience reflects a deeper issue affecting many physicians across the province. Thousands of complex medical procedures, such as emergency surgeries involving multiple doctors, often result in billing disputes or outright rejections. “That means that we aren’t remunerated for some of the most difficult, highly emotional work that stays with you,” she told CBC Toronto.
According to Health Minister Sylvia Jones’s office, more than 99 percent of the 200 million OHIP claims processed each year are paid automatically. However, that still leaves around 1.16 million claims rejected annually. Many of those fall under “complex surgical claims,” which require manual review by non-clinical staff — a process doctors say is often slow, confusing, and demoralizing. OMA president Dr. Zainab Abdurrahman warns that this system discourages physicians from performing innovative or complicated procedures because they fear they won’t be paid.
In response, an arbitrator has ordered both the Ontario government and the OMA to find solutions to the ongoing billing challenges. The OMA is advocating for the reinstatement of “good-faith payments,” allowing doctors to be reimbursed for treating uninsured or critically ill patients without valid health cards. It also wants an OHIP ombudsman’s office staffed with clinical experts to handle complex billing reviews more effectively.
While the province insists that most issues are resolved within 30 days and that doctors can appeal decisions, physicians argue that bureaucratic red tape continues to take time away from patient care. “We want to spend more time with patients, not paperwork,” Healey said. As discussions between the OMA and the government continue, the outcome could shape how Ontario compensates doctors for life-and-death work that goes far beyond the limits of a billing code.
