General practitioner – Newsletter 267 & 268

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We are presenting you, below, a summary of newsletters 267 and 268 published by the RAMQ on December 8th. Please note that we are only presenting the important points and that a complete reading of the newsletters is necessary for a good understanding.

1. Remuneration in a designated population clinic – Letter of agreement no 381

This letter of agreement has been effective as of November 1, 2022 and ends March 31, 2023.

This newsletter provides you with LE381 compensation terms and conditions, instructions, and information regarding the use of the consultation log. The list of Designated Population Clinics (DPCs) is available on the continuously updated annexes webpage (Including many other annexes, letters of Agreement, special agreements, and memoranda of understanding).

We are currently ready to receive billing for your services rendered at a DPC. You have 90 days from the date at which this newsletter was published to retroactively bill for your services.

1. Compensation Terms and Billing Instructions

Compensation under LE 381 applies exclusively to services you render during the time slots dedicated to DPC operations. Outside of these time slots, you are compensated according to the general agreement. As of the date at which the DPC has been initiated in a clinic, when you are assigned activities, you may choose to be paid by the act or on an hourly basis. If you have a mixed remuneration, fixed remuneration, or hourly fee in an institution or CLSC, you may choose to maintain your usual method of remuneration when providing services in a DPC, based on the nomination you hold in that establishment.

1.1 Designated private practice

In a private practice, during a DPC agreed-upon time frame, you may choose either of these options daily.

1.2 Designated Institution

For remuneration purposes, a DPC in an institution is deemed a point of service of a CLSC or a CHSGS outpatient clinic. In an institution, depending on the location of the DPC and during the agreed-upon time frame, you may choose either of these options daily.

1.2.1 Visits and examinations supplements

If, during a day of service in a facility’s DPC, you continue to pay for your private practice and you choose to be paid by the act, you are entitled to the following supplements. This provision does not apply if you have opted for the hourly fee (billing code 19684).

1.3 Physician with a nomination in an institution

When you have a regular practice in an institution, you can choose to keep your usual method of remuneration for your DPC activities rather than being remunerated by the actuary or by the hourly fee. You make your choice on a day-to-day basis and do not have to inform the RAMQ other than by following the specific billing instructions for LE 381.

1.4 Physician Paid on a Flat Fee or Hourly Basis

When you maintain your fixed-fee or hourly payment method, you bill your hours on the Demande de paiement – Tarif horaire, honoraires forfaitaires et vacation form (#1215) or the Demande de paiement – Honoraires fixes et salariat form (#1216).

You must enter:

• the number of the facility where you hold a regular nomination.
• the nature of regular services with the time code: XXX402 – Clinical Services in DPC LE 381.

You must respect the number of hours listed on your nomination. You must take into account the allowed areas of dispensing, the day, and the time slot.

1.4.1 Benefits for the Fixed Fee Physician

If you choose not to maintain your usual fixed fee, on the Demande de paiement – Honoraires fixes et salariat form (#1216), enter the leave code 89 for each day or half-day paid under an alternate payment arrangement. You cannot bill this code for a continuous, extended period.

1.5 Physician under a Mixed Remuneration Agreement.  

To bill for services paid under a mixed remuneration agreement in a DPC and, if applicable, for lump sum and supplemental payments, you must:

• Indicate the context element Service rendu selon le mode mixte dans le cadre de la LE 381;
• Enter the facility number where you hold a regular nomination.
• Use the activity and sector codes provided for in your nomination (Annexe I of the annexe XXIII).

2. Flat rate, surcharges, attendance rates and quarterly cap

2.1 Lump Sum per 4 Hour Shift

A flat fee of $156.40 per 4-hour shift in disadvantageous hours, divisible into hours, is payable for services rendered in a DPC, Monday through Friday from 6:00 p.m. to 12:00 a.m. or at any time on Saturday, Sunday, or a holiday. You must use billing code 19686 and enter the start time and end time. However, if the DPC site is already recognized as a Network Access Designated Family Practice Group (GMF-AR), this package replaces the package established in section 4.00 of EP 54. Therefore, when billing for your services, you must use the DPC-specific code rather than billing codes 19893 and 19894.

2.2 Unfavorable Schedule Premiums

For services rendered in a DPC, private office or facility, the hourly rate and supplements are subject to time markups. If applicable, the hourly fee must be billed on two separate lines.

2.3 Increases for different remuneration

The mark-ups applicable for different remuneration under Annexes XII and XII-A apply according to the place of dispensation, considering that you are deemed to meet the conditions specified in paragraph 1.2 of section I of Annex XII. To benefit from these increases, if you practice in a DPC and do not already meet one of these conditions, you must inform the RAMQ of your situation by letter.

2.4 Attendance rate

A patient visit performed under LE 381 is excluded from the attendance rate calculation. When you are performing services in a DPC and the attendance rate is affected as a result, you may inform the parity committee of your situation as provided in paragraph 15.04 of the EP. The parity committee must be assured that you are not being adversely affected by working in a DPC.

2.5 Quarterly Cap

All compensation for service in a DPC is excluded from the calculation of your quarterly gross income for the period in question.

3. Registry of visits

When you are paid on an hourly lump sum, flat fee, or hourly basis under LE 381, you must record any visits made with a patient in the consultation log. We will notify you in a future newsletter when you can register your visits, retroactive to November 1, 2022. Registering a visit in the registry will allow you to benefit from the provisions of LE 381 as well as an appropriate attendance calculation.

Similarly, the primary care nurse practitioner or primary care nurse practitioner candidate exercising in a DPC in partnership with a physician under the provisions of Letter of Understanding No. 229 will be required to complete the visit log.

The situation will be submitted to the parity committee if we find that a physician is not using the registry.

1. Compensation at a Non-Traditional Ambulatory Site – Letter of Agreement No. 382

This letter agreement is effective November 1, 2022, and ends March 31, 2023.

It provides you with LE 382 compensation terms and conditions, pertaining instructions, and information regarding the use of the consultation log. The list of non-traditional ambulatory sites (NTAS) is available on the Continuously Updated Appendices (Appendices, Letters of Agreement, Special Agreements and Memoranda of Understanding) webpage.

We are ready to receive billing for your services rendered at an NTAS. You have 90 days from the date at which this newsletter was published to retroactively bill for your services.

1. Compensation Terms and Billing Instructions

Compensation under LE 382 applies exclusively to services you render during the time slots dedicated to the operations of a NTAS. Outside of these time slots, you are compensated according to the General Agreement. As of the date the NTAS has been initiated, when you are assigned to the activities of that site, you may choose to be paid by the act or on an hourly basis. If you hold a mixed remuneration, fixed remuneration or hourly fee in an institutiona, you may choose to maintain your usual method of remuneration when providing services in the NTAS.

1.1 Designated Institution

For remuneration purposes, a NTAS in an institution is deemed a point of service of a CLSC or a CHSGS outpatient clinic. In an institution, depending on the location of the DPC and during the agreed-upon time frame, you may choose either of these options daily.

1.1.1 Examination Supplements

If, during a day of service in a facility’s DPC, you continue to pay for your private practice and you choose to be paid by the act, you are entitled to the following supplements. This provision does not apply if you have opted for the hourly fee (billing code 19684).

1.2 Physician with a nomination in an institution

When you have a regular practice in an institution, you can choose to keep your usual method of remuneration for your NTAS activities rather than being remunerated by the actuary or by the hourly fee. You make your choice on a day-to-day basis and do not have to inform the RAMQ other than by following the specific billing instructions for LE 382.

1.3 Physician Paid on a Flat Fee or Hourly Basis

When you maintain your fixed-fee or hourly payment method, you bill your hours on the Demande de paiement – Tarif horaire, honoraires forfaitaires et vacation form (#1215) or the Demande de paiement – Honoraires fixes et salariat form (#1216).

You must enter:

• the number of the facility where you hold a regular nomination.
• the nature of regular services with the time code: XXX403 – Clinical Services in NTAS LE 382.

You must respect the number of hours listed on your nomination. You must take into account the allowed areas of dispensing, the day, and the time slot.

1.3.1 Benefits for the Fixed Fee Physician

If you choose not to maintain your usual fixed fee, on the Demande de paiement – Honoraires fixes et salariat form (#1216), enter the leave code 89 for each day or half-day paid under an alternate payment arrangement. You cannot bill this code for a continuous, extended period.

1.4 Physician under a Mixed Remuneration Agreement.

To bill for services paid under a mixed remuneration agreement in a DPC and, if applicable, for lump sum and supplemental payments, you must:

• Indicate the context element Service rendu selon le mode mixte dans le cadre de la LE 382;
• Enter the facility number where you hold a regular nomination.
• Use the activity and sector codes provided for in your nomination (Annexe I of the annexe XXIII).

2. Flat rate, surcharges, attendance rates and quarterly cap

2.1 Lump Sum per 4 Hour Shift

A flat fee of $156.40 per 4-hour shift in adverse schedules, divisible into hours, is payable for services rendered in a NTAS, Monday through Friday from 6:00 p.m. to 12:00 a.m., or at any time on Saturday, Sunday, or holiday. You must use billing code 19686 and enter the start time and end time.

2.2 Unfavourable Hours Markups

For services rendered in a NTAS, with the exception of services rendered in a designated NTAS outpatient clinic, the hourly rate and supplements are subject to the unfavourable hours markups already provided for in section 4.00 of Annex XX. When you choose to be paid by the act, your hours eligible for a markup must be billed separately from those that are not eligible for a markup. If applicable, the hourly rate must be billed on 2 separate lines.

2.3 Increases for different remuneration

The markups applicable for different remuneration under Annexes XII and XII-A apply according to the place of dispensation, considering that you are deemed to meet the conditions specified in paragraph 1.2 of section I of Annex XII. To benefit from these increases, if you practice in a NTAS and do not already meet one of these conditions, you must inform the RAMQ of your situation by letter.

2.4 Attendance rate

A patient visit performed under LE 381 is excluded from the attendance rate calculation. When you are performing services in a DPC and the attendance rate is affected as a result, you may inform the parity committee of your situation as provided in paragraph 15.04 of the EP. The parity committee must be assured that you are not being adversely affected by working in a DPC.

2.5 Quarterly Cap

All compensation for service in a DPC is excluded from the calculation of your quarterly gross income for the period in question.

3. Registry of visits

When you are paid on an hourly lump sum, flat fee, or hourly basis under LE 381, you must record any visits made with a patient in the consultation log. We will notify you in a future newsletter when you can register your visits, retroactive to November 1, 2022. Registering a visit in the registry will allow you to benefit from the provisions of LE 381 as well as an appropriate attendance calculation.

Similarly, the primary care nurse practitioner or primary care nurse practitioner candidate exercising in a DPC in partnership with a physician under the provisions of Letter of Understanding No. 229 will be required to complete the visit log.

The situation will be submitted to the parity committee if we find that a physician is not using the registry.