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. See omnystudio.com/listener for privacy information.
