Charging for Uninsured Professional Services

I am with Alberta Precision Lab services and we frequently observe that a practitioner charges for their services to the patients in the setting of when uninsured services are provided but not for any related cost for provide diagnostic testing they ordered. Can the revised standard give clarification about how any diagnostic tests ordered as part of an uninsured visit, during which the practitioner charges for their services, should be covered? E.g. should the practitioner charge for those and then pay DI or APL? At least clarity that also any diagnostic test should be charged to the patient under the same terms would be helpful, since there is no reliable way for APL to know in every case that a practitioner orders lab test during an uninsured or medically no necessary visits/patient encounter.

Thank you for the opportunity to comment on Charging for Uninsured Professional Services SOP. It is clear and an improvement on the previous document. I wonder about how best to ensure that undergraduate and postgraduate health professionals are made aware of these and other documents. While the "devil in the details" may be disarming, the CPSA's SOP approach is vital to quality, safety and quality improvement. Who within the CPSA and our respective medical schools are collaborating on this?

Thank you for the opportunity to provide feedback on Consultation 31.
I support the proposed revisions as they emphasize fairness, transparency, and accountability in the physician–patient relationship.
In particular, clarifying expectations for uninsured professional service charges and non-treating medical examinations will help reduce misunderstandings and maintain patient trust.
The focus on professional responsibility and compliance with the Health Information Act when responding to third-party requests is also commendable.
Overall, these updates strengthen ethical standards and support both patient-centered care and professional integrity within Alberta’s medical community.

My primary concern with this is the placement of the clause highlighting that fees for uninsured services must take into account patients' ability to pay - it's been moved from section 1.3 to 6.c. in the proposed structure, effectively de-emphasizing it. Unfortunately many Government of Alberta social programs require forms (such as Alberta Works medicals, or applying for disability tax credit forms for AISH recipients) which are not reimbursed. I have seen multiple patients reporting charges of over $100 for completing these forms; while this does accurately reflect the time and effort that goes into these forms, Alberta Works and AISH recipients are definitionally living in poverty, and these charges represent a substantial proportion of their income. This is done under the current standard, and I fear that moving this clause further down the "batting order" will increase the number of charges which are unsustainable to patients.

Thanks for the opportunity to review the proposed standard. I have 2 pieces of feedback:
1. The AMA has not updated the guide for uninsured services since 2018. It would be necessary to confirm with the AMA that they have plans to keep this document current before tying it to a standard - to my knowledge, there have not been any plans to update the AMA guide, though that may change if you have discussions with them about this draft standard.
2. The piece about requiring a 24 hour messaging service or voicemail is overly prescriptive (also outdated) and unnecessary. Appointments are generally booked online in our office these days and can be cancelled online as well. We have not had an answering machine accept messages for many years now as patients would leave inappropriate information on there waiting for a call back rather than seeking appropriate after hours care. It was dangerous and so we stopped accepting messages, though they are still given a message about how to access after hours care. We always made exceptions for patients that called early Monday morning to cancel - they were not charged if they weren't able to notify us because we were closed. Less prescriptive solutions and language would be preferable here please.

Regarding charging fees for cancelling appointment with less than 24 hours notice, this allows patients to call on a Friday at 6PM to cancel an appointment on Monday at 8AM. The reason I charge fees isn't to make money - it serves as a reminder to patients that physicians are not taxpayer employees. Physicians, their staff, and their patients deserve to be respected by their patients. It is not OK to cancel at the last minute or no-show. I would never do that to my family, friends or my physicians. Last minute cancellations and no-shows reduce our ability to care for other patients and contributes to longer wait times. Changing this recommendation is in the best interests of the majority of patients. Fees should be chargeable when patients cancel with less than 3 business days notice.

Regarding the section about refusing care for a patient who has outstanding fees, I think this should apply only to urgent or emergent problems. This section goes on to refer to another standard that says we can refuse to book subsequent appointments if we sever the relationship. Some patients just need to be reminded that the physician-patient relationship is a two-way street - it must be respectful in both directions. Charging patients is a tangible reminder that there is a consequence for being disrespectful. But, once that's acknowledged, I am happy to keep caring for them with re-established mutual respect. I shouldn't have to fire them, and a fee serves to help correct the course of our professional relationship. And, remember, at the end the day, physicians can only afford their overhead when they see patients. That is the system in which we work. A standard that facilitates bad patient behaviour is not how one supports and reinforces the need for the relationship to be mutually respectful. While these comments apply to a minority, it is a large enough proportion such that it's not acceptable for the College to compel physicians (and indirectly, their other patients) to suffer the consequences of those that are unwilling to be respectful.

1. Pricing limitations undermine professional autonomy and market efficiency

The policy mandates that fees for uninsured services “must reasonably reflect professional costs, administrative costs, and the patient’s ability to pay.” This limits the physician’s autonomy in setting prices and disregards the fundamental principle that the value of professional expertise and time varies based on market demand, patient context, and unique circumstances in each practice.

By requiring prices to be “reasonable,” the standard introduces ambiguity, which could chill innovation or competitive differentiation in service delivery. Physicians should be free to price according to their value proposition without being second-guessed by regulatory bodies, provided services remain legal and patients have choice.

2. Compulsory fee disclosures before service are redundant and may disrupt care

The obligation to disclose or itemize all fees in advance of care for uninsured services places an undue administrative burden and could delay care, particularly in fast-paced or emotionally charged patient encounters. Informed patients can always request a fee schedule; a regulatory mandate for up-front disclosure micromanages professional judgment in communicating with patients.

3. Restrictions on signage, notices, and delegation of communication are inflexible

The stipulation that “a general notice to patients is not sufficient” and that only the physician can make final decisions about fee disputes is unduly rigid. In larger medical practices or clinics, trained staff or electronic systems can efficiently communicate policies and handle most fee-related interactions, freeing up physicians to focus on clinical matters.

4. Prohibition of advance payments for urgent services limits practice sustainability

Forbidding collection of payment in advance for uninsured urgent services that are not available elsewhere is illogical: it exposes practices to non-payment risks and may encourage abuse of these services by patients with no intention of paying. Physicians should have flexibility in managing financial risks in situations where the public system is not responsive.

5. Ban on fees for professional “availability” ignores the realities of standby care

Disallowing fees for simply “being available” undervalues the significant professional and opportunity costs clinicians assume by making themselves accessible. Standby arrangements, especially in remote or concierge settings, are valuable and deserving of compensation—even if a specific act of care is not ultimately required.

6. Block fee constraints undermine innovation in practice delivery

The requirements around block fees—such as forced patient choice and written disclosures—create barriers to innovative service packages and may stifle creative solutions for practice sustainability. In comparable industries, bundling and subscription offerings are commonplace; restricting physicians in this area inhibits the evolution of medical business models, especially in the face of underfunding of public services.

7. Anti-preferential treatment and cross-compensation rules are problematic

The instruction that block fee payers cannot receive preferential access, and that no block fee can include services otherwise compensated, is overly prescriptive. In competitive markets, incentive structures (like loyalty rewards or bundled perks) are standard practice—so long as core insured services are not denied, flexibility in practice management should be preserved.

Conclusion: The document’s recommendations, though well-intended, impede physician autonomy, business model innovation, and economic sustainability. More flexible, market-driven approaches—tempered with laws against clear abuses—are preferable to heavy-handed regulatory micromanagement.

Perhaps it's worth thinking more broadly about “uninsured services”? Services paid for by the AHCIP (e.g. listed in the SOMB) are called "insured services”. But AHCIP isn’t insurance in the usual sense - funding by provincial/federal taxes isn’t the same as premiums, AHCIP doesn't adjust for risk, there are no deductibles or copayments, etc. The key is really that these physician services have been deemed "medically necessary" at some point (or at least, included in the SOMB), and therefore payed for by government. But the Alberta government also pays for physician services via ARPs, the new PCPCM for primary care docs (which includes time spent on "indirect patient care" and "practice management"), and other payment mechanisms. How do these services fit into the definitions of “insured” vs “uninsured” services?

Docs are also payed via truly insurance-like structures (e.g. WCB), and by a whole raft of third-party payers (e.g. AISH, insurance companies, employers). CPSA-regulated members can also opt-out of AHCIP altogether, and be paid *only* by patients, commercial ("private") health insurance, "executive benefits" programs, etc. It’s worth thinking about Alberta docs who opt out of AHCIP (same for those rare Alberta patients who opt-out), as it’s a blind spot in this Standard. What I’m getting at is that the Standard should probably be “Charging Patients for Professional Services” rather than “Block Fees & Charging for Uninsured Professional Services”?

Speaking of insurance - block fees are essentially healthcare insurance SOLD BY PHYSICIANS for services not paid by AHCIP. Pts pay a fixed amount (i.e. premium), hoping they'll come out ahead compared to paying individual service fees (i.e. deductibles). And docs get their block fee/“premium” up front, so they're not chasing pts for fees at-time-of-service.

I think adding the line “Uninsured professional services do not include the costs of maintaining an office, maintaining medical records or arranging appropriate medical referrals” opens a can of worms:
- some docs must pay “the costs of maintaining an office, maintaining medical records”, etc, and some docs don’t pay these costs because AHS pays them
- if we’re assuming that AHCIP fees should include an amount to cover overhead costs, then presumably a fee charged to a patient should also include overhead costs, even if not itemized as such?
- calling out “arranging appropriate medical referrals” (what about surgical referrals?!) doesn’t make much sense, relative to all the other things docs do for patients. And definitely scrap “appropriate” - unless patients should be charged for inappropriate referrals?
- this line contradicts paragraph 3, if “administrative costs” is read to mean overhead.

The definition of “Insured services” is problematic, as “medically required” is too open to interpretation - it should really just mean “what AHCIP pays for, as defined in the SOMB”. But again, what about ARPs, the PCPCM, and other government-funded physician payment structures?

I personally agree with the section on block fees, which effectively treats these as optional “fees paid as a block”, rather than the way they’ve started to become used to skirt the differentiation of public from private payment for clinic services. Raising the bar, for those using this tool, will help keep this in check. I particularly like the items around transparency for patients. If we docs were on the other side of the counter, being offered a “block fee” option by our own doctor, I think these are the guardrails we’d appreciate having.

For missed appointments, paragraph 12.d - “ensure charges reasonably reflect the actual costs incurred” - is tricky. Many clinics currently use escalating charges, as an attempt to modify patient behaviour around missed appointments, but not rationalized around “costs incurred”. For that matter, there are no costs incurred specifically by missed appointments, only revenue not gained - perhaps “ensure charges reasonably reflect lost revenue” would be better? Many clinics also leverage inability to book further appointments until missed visit charges are paid, also to attempt behaviour change. Personally, I think the underlying reasons most patients miss (or recurrently miss) appointments are only counterbalanced by these tools for a small subset of patients, while causing significant harm to the majority of patients for whom they are not effective countermeasures, so I’m in favour of rationalizing the handling of missed appointments around missed revenue rather than behaviour modification tools. However, to fill the void in how clinics manage missed appointments, it would be very helpful if the CPSA could develop resources on more effective tools clinics can use for this.