In Ontario, family doctors are the gateway to the healthcare system, including providing a referral for a specialist. If you are one of the nearly 2 million Ontarians without a family doctor and need to see a specialist, say a gynaecologist, it can be incredibly challenging to get the care you need.

Nam Kiwanuka speaks to Dr. Zainab Abdurrahman, the president of the Ontario Medical Association about the crisis in public healthcare.

Got a question or comment? Email us at: mistreatedpodcast@tvo.org

If you, or someone you know, is struggling with mental health, visit any of the following resources for support: Canada.ca/mental-health Kids Help Phone Call 1-800-668-6868 (toll-free) or text CONNECT to 686868.

The Government of Ontario's Mental Health Support Resources: https://www.ontario.ca/page/find-mental-health-support

Follow TVO on social: https://www.youtube.com/theagenda https://www.instagram.com/mistreatedtvo

Join our newsletter: https://www.tvo.org/newsletters

Visit the TVO Today website for current affairs journalism, documentaries and podcasts: https://www.tvo.org

Research links

Meet the first Black woman elected to represent Ontario doctors: https://www.cbc.ca/news/canada/london/meet-the-first-black-woman-elected-to-represent-ontario-doctors-1.7525349

Gynecologic Surgery Delayed for Up to 3 Years in Canada: https://www.medscape.com/viewarticle/gynecologic-surgery-delayed-3-years-canada-2025a1000iev?form=fpf

A Toronto-area doctor spent 10 days caring for a dying baby without pay. Here’s why she’s speaking up: https://www.cbc.ca/news/canada/toronto/doctors-ontario-ohip-billing-rejected-9.6958953

Ontario, medical association near new compensation deal they say will help retain, recruit family

Ontario Government and Ontario Medical Association Confirm Funding Increase That Will Protect Provincial Health Care: https://news.ontario.ca/en/release/1005805/ontario-government-and-ontario-medical-association-confirm-funding-increase-that-will-protect-provincial-health-care

Ontario, medical association near new compensation deal they say will help retain, recruit family doctors: https://www.cbc.ca/news/canada/toronto/ontario-family-doctors-new-contract-1.7602189

Province's response:

Ontario's Medical Claims Payment System (MCPS) efficiently processed more than 200 million claims annually. To be clear, over 99% of these claims are paid automatically, exactly as submitted, reflecting the system's productivity.

Only a small fraction, 0.58%, of all claims are sent for manual review, and even among these, more than 95% are resolved within 30 days. In general, two thirds of these claims are categorized as Complex Surgical Claims, where there are multiple procedures performed, and where a three-tier review process, as is used in a manual review, is fitting.

Claims are reviewed in three tiers. A Claims Assessor handles the initial review, and if deemed necessary, it is escalated to an Assessment Officer, who further evaluates the claim and supporting context. More nuanced cases go to a Medical Advisor, a physician, for final review. Outcomes include full payment, partial payment, or return to the provider, and physicians can appeal with additional information.

This reliable, structured process ensures that claims subjected to manual review comprehensively align with the payment requirements of the Schedule of Benefits.

It’s ultimately disappointing that the OMA is choosing to focus on .58% of OHIP claims, rather than highlighting the real progress we’ve made together to support physicians.

In Ontario, family doctors are the gateway to the healthcare system, including providing a referral for a specialist. If you are one of the nearly 2 million Ontarians without a family doctor and need to see a specialist, say a gynaecologist, it can be incredibly challenging to get the care you need.
Nam Kiwanuka speaks to Dr. Zainab Abdurrahman, the president of the Ontario Medical Association about the crisis in public healthcare.
Got a question or comment? Email us at: <a href="mailto:mistreatedpodcast@tvo.org">mistreatedpodcast@tvo.org</a>
If you, or someone you know, is struggling with mental health, visit any of the following resources for support: Canada.ca/mental-health Kids Help Phone Call 1-800-668-6868 (toll-free) or text CONNECT to 686868.
The Government of Ontario's Mental Health Support Resources: <a href="https://www.ontario.ca/page/find-mental-health-support">https://www.ontario.ca/page/find-mental-health-support</a>
Follow TVO on social: https://www.youtube.com/theagenda <a href="https://www.instagram.com/mistreatedtvo">https://www.instagram.com/mistreatedtvo</a>
Join our newsletter: <a href="https://www.tvo.org/newsletters">https://www.tvo.org/newsletters</a>
Visit the TVO Today website for current affairs journalism, documentaries and podcasts: <a href="https://www.tvo.org">https://www.tvo.org</a>
Research links
Meet the first Black woman elected to represent Ontario doctors:&nbsp;<a href="https://can01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cbc.ca%2Fnews%2Fcanada%2Flondon%2Fmeet-the-first-black-woman-elected-to-represent-ontario-doctors-1.7525349&amp;data=05%7C02%7Cmomara%40tvo.org%7C29370b9922a148ccd5c808de681db239%7C2eadfde0e18641eb8f621e033d56dcbe%7C0%7C0%7C639062673953063649%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&amp;sdata=4im%2BGphdgKmb%2FX8rzar6HXAvhaTAoUz0C%2FRiQHiQaVw%3D&amp;reserved=0" data-ogsc="" data-outlook-id="5e0b7f15-ac4b-4f15-bad1-fced7b5d27d7">https://www.cbc.ca/news/canada/london/meet-the-first-black-woman-elected-to-represent-ontario-doctors-1.7525349</a>
Gynecologic Surgery Delayed for Up to 3 Years in Canada: <a href="https://can01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.medscape.com%2Fviewarticle%2Fgynecologic-surgery-delayed-3-years-canada-2025a1000iev%3Fform%3Dfpf&amp;data=05%7C02%7Cmomara%40tvo.org%7C29370b9922a148ccd5c808de681db239%7C2eadfde0e18641eb8f621e033d56dcbe%7C0%7C0%7C639062673953167847%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&amp;sdata=x6nBjLUnqeHAfG0xaD%2Fh%2Bs4RmN2tlSXteQCI0r%2FKq6w%3D&amp;reserved=0" data-ogsc="" data-outlook-id="a387e9f4-aa0e-45e6-922c-d310f15e41e0">https://www.medscape.com/viewarticle/gynecologic-surgery-delayed-3-years-canada-2025a1000iev?form=fpf</a>
A Toronto-area doctor spent 10 days caring for a dying baby without pay. Here&rsquo;s why she&rsquo;s speaking up: <a href="https://can01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cbc.ca%2Fnews%2Fcanada%2Ftoronto%2Fdoctors-ontario-ohip-billing-rejected-9.6958953&amp;data=05%7C02%7Cmomara%40tvo.org%7C29370b9922a148ccd5c808de681db239%7C2eadfde0e18641eb8f621e033d56dcbe%7C0%7C0%7C639062673953208117%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&amp;sdata=MJAV7pZWMEYOWDn4STnhYGqHzLOcMcYoA4DDrHrOXXI%3D&amp;reserved=0" data-ogsc="" data-outlook-id="d6b541a1-50ba-4e45-bd63-91942351377b">https://www.cbc.ca/news/canada/toronto/doctors-ontario-ohip-billing-rejected-9.6958953</a>
Ontario, medical association near new compensation deal they say will help retain, recruit family
Ontario Government and Ontario Medical Association Confirm Funding Increase That Will Protect Provincial Health Care: <a href="https://can01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnews.ontario.ca%2Fen%2Frelease%2F1005805%2Fontario-government-and-ontario-medical-association-confirm-funding-increase-that-will-protect-provincial-health-care&amp;data=05%7C02%7Cmomara%40tvo.org%7C29370b9922a148ccd5c808de681db239%7C2eadfde0e18641eb8f621e033d56dcbe%7C0%7C0%7C639062673953272308%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&amp;sdata=Fm2pNg7C1LCdvhcWAfMvViG36xBaJivbG1XBwpFmruk%3D&amp;reserved=0" data-ogsc="" data-outlook-id="1b371ac1-0917-438c-a46c-009627b0d2ec">https://news.ontario.ca/en/release/1005805/ontario-government-and-ontario-medical-association-confirm-funding-increase-that-will-protect-provincial-health-care</a>
Ontario, medical association near new compensation deal they say will help retain, recruit family doctors: <a href="https://www.cbc.ca/news/canada/toronto/ontario-family-doctors-new-contract-1.7602189">https://www.cbc.ca/news/canada/toronto/ontario-family-doctors-new-contract-1.7602189</a>
Province's response:
Ontario's Medical Claims Payment System (MCPS) efficiently processed more than 200 million claims annually. To be clear, over 99% of these claims are paid automatically, exactly as submitted, reflecting the system's productivity.
Only a small fraction, 0.58%, of all claims are sent for manual review, and even among these, more than 95% are resolved within 30 days. In general, two thirds of these claims are categorized as Complex Surgical Claims, where there are multiple procedures performed, and where a three-tier review process, as is used in a manual review, is fitting.
Claims are reviewed in three tiers. A Claims Assessor handles the initial review, and if deemed necessary, it is escalated to an Assessment Officer, who further evaluates the claim and supporting context. More nuanced cases go to a Medical Advisor, a physician, for final review. Outcomes include full payment, partial payment, or return to the provider, and physicians can appeal with additional information.
This reliable, structured process ensures that claims subjected to manual review comprehensively align with the payment requirements of the Schedule of Benefits.
It&rsquo;s ultimately&nbsp;disappointing that the OMA is choosing to focus on .58% of OHIP claims, rather than highlighting the real progress we&rsquo;ve made together to support physicians.

(MIS)Treated, a TVO podcast, explores how medicine has – and still is – failing women and speaks to the people looking to make a difference. Join host Nam Kiwanuka to hear real life stories and expert interviews on how the mistreatment and misdiagnosis of women affects us all.

(MIS)Treated, a TVO podcast, explores how medicine has &ndash; and still is &ndash; failing women and speaks to the people looking to make a difference. Join host Nam Kiwanuka to hear real life stories and expert interviews on how the mistreatment and misdiagnosis of women affects us all.