The OHIP Premiums Family Physicians Leave on the Table

Most unbilled OHIP revenue isn't exotic. It's premiums — small add-on codes attached to visits you're already billing — that get skipped because they're easy to forget at 6 p.m., because nobody ever explained the eligibility rules, or because your billing workflow doesn't surface them.

Individually they look trivial: $8, $25, 30%. Across a year of full clinic days they routinely add up to five figures. Here are the ones family physicians miss most, with current Schedule of Benefits fees.

(Fees below are the current SOB provider amounts. Eligibility conditions apply to every one of them — the point of this post is to know when to check.)

1. After-hours premium — Q012 (+30%)

If you're in a patient enrolment model and seeing your enrolled patients during designated after-hours blocks (evenings, weekends), Q012 adds 30% on top of eligible assessments. A $44.55 intermediate assessment (A007) becomes ~$57.90 — for work you were doing anyway.

Why it's missed: it has to be added per-visit, and by the evening clinic block everyone is tired. This is exactly the kind of premium software should add automatically based on the time of service.

2. Special visit premiums — the B-codes

Seeing a patient non-electively outside regular hours, or travelling to see them, triggers special visit premiums that many physicians never bill:

| Situation | Code | First person seen | |-----------|------|------------------| | Weekday evening (17:00–24:00), non-elective, office | B992 | $45.25 | | Special visit premium | B993 | $84.80 | | Special visit to patient's home | B994 | $67.85 | | Home visit at night | B996 | $113.10 |

These stack on top of the assessment itself. A single after-hours call-back you didn't bill a premium for can be $45–113 gone.

Why it's missed: the "first person seen" / subsequent-person structure and elective-vs-non-elective rules feel risky, so physicians skip them entirely rather than bill them wrong.

3. First visit after hospital discharge — E080 ($25.90)

Your enrolled patient was discharged from hospital and you see them for follow-up within the eligible window: add E080. It exists precisely to reward the post-discharge continuity visit you're already doing.

Why it's missed: you'd have to know (and remember) that the patient was just discharged. If your billing tool doesn't connect that context, the premium never gets added.

4. MRP premiums for inpatient work — E082 / E083 / E084

If you're the Most Responsible Physician for admitted patients:

• E082 — admission assessment premium: +30%
• E083 — subsequent inpatient visits: +30%
• E084 — weekend/holiday subsequent visits: +45%

For a hospitalist stretch or shared inpatient coverage, forgetting the MRP premium on every subsequent visit compounds fast — it's 30–45% of your ward billing.

Why it's missed: rounding lists get billed in a hurry. Every patient on the list needs the premium attached, every day.

5. Chronic disease and prevention codes

Not premiums strictly, but the same failure mode — billable work hiding inside visits you're coding as plain assessments:

• K030 — Diabetic management assessment: $45.75. If the visit met the K030 requirements and you billed an A007 instead, you left money and a tracking code behind.
• G512 — Palliative care case management: $67.75.
• K130 / K131 — Periodic health visit (adolescent $87.10 / adult 18–64 $64.25) — instead of coding the "annual check-up" as an intermediate assessment.
• E079 — Initial smoking cessation discussion: $15.95 for a conversation many physicians have weekly and bill never.
• G700 — +$8.80 fee-per-visit premium on procedures marked (+) in the Schedule.

The pattern

Every item on this list fails the same way: the premium depends on context — time of day, enrolment status, discharge events, MRP status, visit content — that isn't written on the fee code itself. Human memory is a bad database for that context at the end of a clinic day.

Three fixes, in increasing order of effectiveness:

1. Cheat sheet taped to your monitor with your five most-applicable premiums. Free, helps somewhat.
2. End-of-day review — scan the day sheet once before submitting and ask "which of these visits was after hours, post-discharge, or chronic-disease work?"
3. Software that surfaces premiums automatically. SnapBill checks every claim against the Schedule of Benefits before submission and flags eligible premiums — after-hours timing, MRP add-ons, code pairings — while you bill, with a plain-language note on why the premium applies, so you learn the rule instead of re-missing it. If you photograph your rounding list, premiums are included in the drafted claims from the start.

The Schedule of Benefits already pays for this work. The only question is whether your workflow captures it.

---

Want your premiums caught automatically? SnapBill reviews every claim against the SOB before it goes out — sign up free, your first 3 months are on us. New grads: your whole first year is covered.