Canada: Changes Introduced To The Schedule Of Benefits To Reflect Recommendations Of The Appropriateness Working Group

Health Law Bulletin
Last Updated: October 17 2019
Article by Lynne Golding and Sophie MacRae

Effective October 1, 2019, the Schedule of Benefits for Physician Services (the "Schedule") and Ontario Regulation 965 under the Public Hospitals Act ("Regulation 965") will be amended to reflect recommendations of the physician-led Appropriateness Working Group (the "AWG"). Our previous bulletin, "Physician Payment Discounts End Effective April 1, 2019: An Overview of the Arbitration Process and Other Key Outcomes" discussed the outcome of the arbitration between the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association ("OMA"). While a significant outcome of the arbitration was an end to payment discounts on physician fees, the decision also resulted in two new working groups: one on "appropriateness" and another on primary care.

On August 22, 2019, the AWG submitted its first 11 recommendations. The recommendations were accepted by the Minister of Health and the OMA and take effect on October 1, 2019. Among them are reduced fees for house calls, duplicative referrals and assessments from primary care providers.

Purpose of the AWG

A hard fee cap on physician billings was rejected in the arbitration decision. In so ruling, the arbitrator observed that it is within the government's power to delist inappropriate services from the Schedule. The purpose of the AWG is to recommend changes to the Schedule that will result in cost savings and shorter wait times by reducing unnecessary services and services that are no longer supported by best available evidence. The AWG has acknowledged that technology and knowledge evolve, and so should the Schedule.

When established by the arbitration decision, the AWG's goal was to find $100 million in savings in this government fiscal year (to March 31, 2020), and $360 million in savings in the next fiscal year. It is expected that more recommendations are to come.

The Recommendations

Using current standards and best practices, the AWG made 11 recommendations in two thematic areas: to improve patient care and to reduce medically unnecessary services. The following is a brief overview of the recommendations.

Improve patient care:

  • Use more accurate diagnostic imaging for sinus problems by removing the fee code for sinus x-rays.
  • Make patient referrals to new province-wide musculoskeletal rapid access clinics for chronic hip and knee pain for arthritic care. The intention is to create greater access to CT and MRI imaging for patients who need it. Physiotherapists, nurses and doctors at the new clinics will determine which patients require imaging.
  • Update the use of ambulatory cardiac monitoring devices with new minimum technical requirements for outpatients. Loop recorders, considered out dated technology, will no longer be funded.
  • Eliminate the requirement for a referral to see a specialist for the same problem within a two year period. "Consultations" (a thorough assessment rendered following a written request from a referring physician or nurse practitioner) rendered by the same consultant to the same patient for the same diagnosis will only eligible for payment as such once every 24 months when provided in the office, and every 12 months in the hospital or emergency department. Any additional examinations and assessments are payable using the appropriate assessment code.
  • Fund more effective infertility testing and offer alternative tests only based on physician judgment and patient circumstances.

Reduce medically unnecessary services:

  • Perform ear wax removal procedure only when medically necessary (when it is causing hearing loss or is needed to treat/diagnose other issues).
  • Only include larynx examinations with stomach examinations when there is evidence of a problem.
  • Only offer urine pregnancy tests when there is an immediate need. These tests are often given in addition to a blood test, which is more effective.
  • Reduce pre-operative assessments to those conducted by surgeons and anesthesiologists. Assessments by family doctors are not necessary.
  • Provide knee arthroscopies only for degenerative knee disease in special circumstances, otherwise offer non-operative therapies.
  • Fund physician premiums for house calls only for frail elderly and housebound patients. Physicians offering home visits to patients who do not meet the requirements of the premium may use the appropriate assessment fee code for the service provided.

The amendments to Regulation 965 will enact the recommendation to eliminate the requirement for a family physician to conduct a duplicative pre-operative history, physical and assessment, in conjunction with the associated de-listing from the Schedule. When a medically necessary consultation by a specialist is required prior to a dental or surgical procedure in a hospital, that service remains eligible. According to the Ontario Hospital Association ("OHA"), assessments from surgeons and anesthesiologists are consistent with current practice, and there is no longer any regulatory requirement for a stand-alone complete history, physical and assessment from a family doctor. The OHA recommends that hospitals review their existing policies.

Other Schedule Changes

In 2017, the OMA and Ministry of Health and Long-Term Care established a working group to review Team Care in Teaching Units. In addition to the recommendations of the AWG, the Schedule has been updated to rename this section the Supervision of Postgraduate Medical Trainees and to clarify when supervising physicians can bill for services performed by trainees.

New codes have also been created for the use of Rubidium for cardiac perfusion PET and the application of SPECT.

Specific fee codes for all of the changes can be found in the Ministry of Health's Info Bulletin #4726, available here.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on

Click to Login as an existing user or Register so you can print this article.

In association with
Related Topics
Related Articles
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of

To Use you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions