Ontario optometry exam fees were the last thing on my mind as an optometrist trained in the US and then returning to my hometown in Ontario, Canada. There was a learning curve with how to bill for eye exam services, what diagnostic codes to input after the patient’s exam, and how to get paid for the services that I provided.
When we were students of optometry, we never focused our studies on insurance billings and payments for certain tests and assessments. Instead, a lot of the coding and billing had to be learned after entering into the real world and when in practice.
There are some differences between how optometric services are billed and coded in the US compared to how it is done in Canadian practices. In this article, I will primarily focus on how optometrists in Ontario collect payments for their services and what it is like to bill for Ontario government insured plans for 2018.
Earnings and income potential in Ontario:
Like many other places of practice in North America, your income and earning potential will be highly dependent on the volume of patients you see at your practice, services offered, and the amount of sales made. In Ontario, due to the benefits of OHIP that allow patients to receive regularly scheduled eye exams, your earnings could be quite different if your demographic is primarily made up of OHIP services compared to cash or privately insured exam services. This may be an important factor in selecting your choice of location to practice.
In Ontario, residents are fortunate to have this government-run health insurance plan, funded by taxpayers and the Canadian government, to allow for free access to key emergency, preventative care and medical services.
Who sets the exam fee in Ontario?
Optometrists can set their own fees for eye exam services offered. Services may include standard eye exams, problem-specific visits, follow-up appointments, contact lens assessments and fittings, additional visual field testing or retinal imaging, orthokeratology, vision therapy, and more. The average cost of a standard eye exam can vary between each private clinic or optometric facility depending on the type of additional services offered. Optometry clinics within the same neighborhoods typically charge a similar exam fee or offer similar fee structure to stay competitive.
Private/Corporate (Third Party) Insurance Plan:
Patients with own private or corporate insurance plan for eye care coverage usually have a maximum claimable amount for optometric services, eye wear, contact lenses, etc. per time period. Some extended healthcare benefits for employees include a separate amount for visual health assessments annually or biannually. It is encouraged that patients check with their insurance provider for more information. Some optometrists can directly bill the third party insurance provider on behalf of the patient, but more often, patients will pay for their exam visit and submit their issued receipt to their own insurance provider and then get reimbursed for the service they received. Insurance companies will pay for the full or part of the exam fee and the patient might have to pay the remaining balance on the day of the visit. In instances where patients do not have their own insurance plan for coverage on visual health assessments, the exam fee will be paid out of the patient’s own pocket on the day of the service.
Provincial Insurance Coverage (Ontario Health Insurance Plan):
A variety of health care services are provided for the citizens of Ontario in Canada. Ontario health insurance coverage is for Canadian citizens with a primary place of residence in Ontario or those who are physically present in Ontario for a certain period during the year. Check out OHIP’s list for more details about who’s qualified for OHIP.
Annual eye exams are part of the insured services to which the younger and senior populations are entitled. To see full list of health care services, please visit the OHIP website.
Ontario Health Insurance Plan (OHIP) fee schedule:
The exam fee for the children (19 years and younger) and the elderly (65 years and older) is set by the Ontario government.
Optometrists in Ontario will also provide annual or biannual exams for individuals who have social assistance for work disability or medical conditions as long as their government insured plans are valid. You can find further coverage details at the website for the Ministry of Children, Community, and Social Services.
Individuals that are eligible for OHIP benefits will not need to pay out of pocket for the basic eye service received.
Optometrists receive $42.50 for every full exam for children up to 19 years old and $47.00 for senior eye exams as of 2018. For individuals between 20-64 years old with medical conditions, their exam fee is $43.80. For any follow-up or partial assessments for patients covered by OHIP, $25.15 is paid to the optometrist from the government. The service fee structure is already set province-wide regardless of the optometrists’ own standard eye exam fee. Make sure to familiarize yourself with the service fee structure!
If additional testing such as contact lens fittings, retinal imaging, and other therapies are required for a more thorough health assessment, the patient will be required to pay the service charge determined by the optometrist.
Although the reimbursement to optometrists for each OHIP eye exam is not as much as what you can potentially charge for a self-paying patient, as an eye care professional in Ontario, it is essential that you provide the highest level of care to your patients regardless if they are self-paying or OHIP covered.