Dr. Braden Gammon remembers the rush of adrenaline he felt when he rushed into the operating room three years ago to examine a patient whose arm had been crushed by farm equipment.
The young farmer had lost four fingers, but Gammon, an Ottawa hand and wrist surgeon, wanted to try to restore the crippled hand.
Working through the night, Gammon slowly reattached each finger, carefully realigning bones, connecting tendons, and suturing blood vessels no wider than a strand of spaghetti.
The 15-hour operation was successful. But it was two and a half years before Gammon said the provincial government reimbursed him for his work. Until then, the only payment he had received since his November 2022 surgery was a jug of maple syrup from a grateful farmer.
“It's ridiculous,” said Gammon, an orthopedic surgeon at The Ottawa Hospital. “Those fingers didn’t magically connect.”
The case is a dramatic but increasingly common example of how long-standing OHIP billing problems are affecting doctors across the province, according to the Ontario Medical Association.
He warns that Ontario's outdated OHIP billing system forces doctors to wait months for late payments, and the hours spent reviewing denied or unresolved claims is leading to physician burnout and taking time away from caring for patients.
The problems have become so widespread in recent years that the OMA says it is now a top concern for its members. On Monday, a doctors' rights group called on the provincial government to take action. OHIP billing system update top health priority.
While billing issues affect a range of physicians (the 2025 OMA survey found that 90 percent of respondents said they had claims denied in the past year), the problems are particularly acute for surgical specialists. The OMA says the billing system has not kept pace with surgical innovation and often fails to account for new or more complex surgeries. This has led to some doctors no longer offering procedures to patients for fear of not getting paid, and others choosing to leave the province.
“My concern is that doctors are so frustrated … that some of them are getting to the point where they just don't want to do (major surgeries) anymore,” said OMA CEO Kimberly Moran. “We don’t want that for our health care system.”
How Ontario Doctors Get Compensated
Ontario physicians are compensated for the insured services they provide according to the OHIP benefit schedule. They file claims using specific fee codes; There are about 6,000 codes in the medical services schedule.
When it is believed that a bill has been billed in error or when a physician is asked to provide additional information about a patient's encounter, this may result in a denial, delay, or reduction of payment. There is an appeals process, but doctors say it is time-consuming and that not all appeals will be granted or resolved quickly.
Gammon is one of the few surgeons willing to speak out about unpaid or pending OHIP claims. He said many of his fellow surgeons have similar experiences, but few want to speak publicly because they fear their OHIP accounts will come under greater scrutiny, leading to further delays.
In the farmer's case, Gammon said his OHIP reimbursement was delayed because he billed for multiple surgical procedures simultaneously under the same anesthesia; For example, the patient required four fingers to be attached rather than just one. This resulted in a manual review, meaning the claim could not be fully processed through the automated OHIP system and was instead sent to the Department of Health for assessment.
In a manual review, doctors must provide detailed documentation of the procedure as proof that they provided services, which can lead to many disputes between the doctor and the ministry. If a physician files a claim or response outside the due date, billing may be delayed, reduced, or denied. Doctors can appeal decisions through a multi-step process that includes requesting an independent audit through the Health Services Appeals and Audit Board.
Gammon said he understands the need for checks and balances to ensure claims are accurate and doctors adhere to benefit schedules. For surgeons, he said, the problem is that OHIP billing codes don't fully reflect the complexity of many procedures, meaning those claims are funneled straight into the manual review process, creating an administrative burden and resulting in delayed or reduced reimbursement.
“I would say the more complex the situation, the more likely it is that there will be a discrepancy between the service provided and the payment received,” said Gammon, an assistant professor at the University of Ottawa. He noted that in his experience in general, OHIP claims face a delay of at least seven to nine months before manual review begins.
The frustration has become so great that Gammon, an expert in helping arthritis patients, no longer offers the specific surgery.
Gammon said the partial wrist fusion procedure is a better option for some patients because it allows for more mobility than a full wrist fusion while reducing pain. But there is no OHIP billing code for this, and Gammon said he has yet to receive reimbursement for the several times he had the surgery.
“When people hear about this, they assume we must have done something wrong,” he said. “But there is no technical error here. The patient has a valid OHIP card. We submitted our bills on time. We resubmitted the bills and requested them multiple times. The delays are entirely the fault of the department.”
Dr. Michael Jacob, a vascular surgeon formerly at Kingston Health Sciences Center and now at The Ottawa Hospital, said his OHIP reimbursement is often delayed by at least six months.
Jilly McIver for Toronto Star
Some surgeons have been kicked out of Ontario
Dr. Michael Jacob, a vascular surgeon formerly at the Kingston Health Sciences Center and now at the Ottawa Hospital, said OHIP compensation The funds surgeons receive are used to finance their practice, including the purchase and maintenance of equipment and office staff. When billing requirements are delayed, it can be difficult to keep their practice afloat, he said.
“For those of us who have experienced this, there is a real, tangible outcome,” he said, noting that his OHIP reimbursement is often delayed by at least six months.
Jacob said his surgical specialty — vascular surgeons, who diagnose and treat diseases of the arteries and veins — is among those most affected by the OHIP reimbursement delay because the department's benefit schedule does not take into account complex vascular procedures or the specialty's pace of growth. He said that while hospitals are aware of surgeons' concerns, they have no direct stake in the payment process and doctors must speak to the ministry.
In recent years, Jacob said he has witnessed a “snowball effect” of chronic underpayment for technically complex procedures that has driven surgical trainees away from his specialty and forced some experienced surgeons to leave the province. He said he knows of at least five vascular surgeons who have left Ontario in the past few years.
“They're just tired of the headaches of providing care and not being compensated for it,” said Jacob, chief of vascular surgery at OMA. Because there are only about 135 vascular surgeons in Ontario, patient wait times are likely to increase if doctors continue to leave the province or specialty, he said.
“We like to take on difficult cases. We like to provide the best surgeries for patients. But the Ontario system doesn't compensate for that.”
What does the Ministry of Health say?
OMA's Moran said the department is aware of the problems with OHIP billing and is working to resolve them, but it's unclear what they are and that doctors have yet to see any changes.
A spokeswoman for Health Minister Sylvia Jones said Ontario's health claims payment system processes more than 200 million claims each year and that 99 per cent are paid automatically as they are submitted, which “reflects the performance of the system.” Ema Popovic said that less than one percent of all claims are submitted manually, and that more than 95 percent of them are resolved within 30 days.
Overall, two-thirds of these claims are labeled as complex surgical claims, in which multiple procedures are performed, she said. The department's three-tier manual review process is appropriate for such cases, Popovich said, noting that detailed cases will move to the third level, where a doctor makes the final review. She said the results include full or partial payment or refund of claims, and that the appeals process is open to doctors.
“This robust, structured process ensures that claims subject to manual review are fully compliant with the payment requirements of the Schedule of Benefits,” Popovich said in a statement.
As part of its advocacy on this issue, OMA is asking the department to create an expedited process for updating and modernizing the benefit schedule so that it can keep pace with advances in medicine and surgery. The OMA also wants greater transparency and faster turnaround times for the review process and is calling on the government to create an OHIP Ombudsman with independent oversight who can intervene and quickly resolve billing issues.
The Department of Health did not respond to questions about whether it would work with OMA on its requests to modernize and streamline the OHIP billing system. Popovich said it was “disappointing that the OMA chooses to focus on the 0.58% of OHIP claims rather than highlighting the real progress we have made together in supporting physicians.”
Although he was finally compensated for the 15-hour hand surgery, Gammon said it remains a prime example of what's wrong with the billing system. After negotiations with the ministry, he stated that he received payment for his services, but at a reduced rate.
“Many surgeons have to perform lengthy and complex procedures, and if we're only paid a fraction of what we think we're owed, that's obviously going to be a real deterrent for us.”
Gammon said he doesn't want people to make the mistake of what he and his colleagues are asking for. It's not about more money or higher salaries – they know Ontario surgeons earn a good income. Instead, they want quick reimbursement for work already completed or for innovative procedures they want to perform.
“We can't wait months or even years to find out whether we'll get paid or not.”
