Policy
The WSIB may establish fee schedules for health care as it considers appropriate.
If the WSIB does not receive a bill for health care within the time it specifies, the WSIB may reduce the amount payable for the health care by a percentage that it considers to be an appropriate penalty.
Health care practitioners cannot request a worker to pay for health care, or any related service provided under the insurance plan.
No action lies against the WSIB to obtain payment of an amount greater than is established in the applicable fee schedule for health care provided to a worker. No action lies against a person other than the WSIB for payment for health care provided to a worker.
Purpose
The purpose of this policy is to outline the health care fees the WSIB may authorize as a result of a work-related injury/disease and the criteria for payment.
Guidelines
The WSIB is responsible for periodically setting and reviewing the rates or fees paid to health care practitioners. For definitions of health professional and health care practitioner, refer to 17-01-02, Entitlement to Health Care.
To ensure that all health care practitioners are aware of the rates paid for their services, the WSIB:
- works with professional associations to establish fee schedules, or
- adopts those established by the Ontario ministry responsible for health.
A list of the WSIB's fee schedules is on wsib.ca.
For more information on specific fees please contact (416) 344-4526 or toll-free 1-800-569-7919.
Hospital services
If a worker has entitlement to hospital services, the hospital charges are paid at rates determined by the WSIB.
In-patient
Standard ward in-patient services are paid according to the Ontario Hospital Inter-Provincial authorized per diem rates set by the Ontario ministry responsible for health. In a public hospital, a worker ordinarily requires standard ward accommodations.
The WSIB makes exceptions if the attending health professional considers that, for medical reasons, other accommodation is required.
All necessary nursing services are included in the hospital's per diem rate.
Workers are not admitted to, or kept in, any hospital for residential care.
Out-patient
The WSIB pays hospital out-patient bills at the approved rates.
Drug payment and WSIB-set professional dispensing fee
The WSIB pays the costs of drugs required by a worker for treatment of a work-related condition. The WSIB also covers the professional dispensing fee, according to its set fee schedule. Payment is made to:
- pharmacies
- physicians who are identified and approved as being eligible to dispense drugs (if drug dispensing services are not available within a reasonable distance)
- pharmacies operating in hospitals approved under the Public Hospitals Act, and
- workers.
Autopsy
If an autopsy helps the WSIB make a decision, the practitioner's fee is paid according to the type of practitioner and the type of case. Payment is made whether the claim is allowed or not.
Photocopies of medical records
The WSIB pays for making photocopies of medical records at approved rates for both in-patients and out-patients.
Late submission of health care bills
Health care practitioners must submit health care bills for payment within 6 months of the service date. Late submission of accounts may result in the following penalties:
- 6 to 9 months-25% fee reduction
- 10 to 12 months-50% fee reduction, and
- more than 12 months-100% reduction.
Late submission penalties are administrative decisions of the WSIB. They are not subject to appeal either through the internal appeals process, or the Workplace Safety and Insurance Appeals Tribunal (WSIAT).
Appointments not kept by worker
The WSIB does not pay for appointments for examination, treatment or for non-economic loss assessments that a worker has missed or cancelled.
Application date
This policy applies to all decisions made on or after December 5, 2024, for all accidents.
Document history
This document replaces 17-03-02 dated October 12, 2004.
This document was previously published as:
17-03-02 dated April 6, 2001.
References
Legislative authority
Workplace Safety and Insurance Act, 1997
Sections 33(3)(4)(5)(6)
Workers' Compensation Act, Revised Statutes of Ontario 1990
Section 50
Approval
Approved by the President and CEO on December 3, 2024.