Virtual Care Billing Across Provinces Is Where Clinics Lose Money

A patient calls from Calgary. You are licensed in Ontario and sitting in Toronto. Can you see them, and will anyone pay you? Those are two different questions, and there is a third hiding underneath them. Almost every mistake in virtual care billing across provinces comes from treating them as one. Separate them, and virtual care billing across provinces becomes a checklist rather than a risk.

Where is the patient sitting?

Licensure follows the patient, not you. Where the patient is physically located at the time of the visit determines whose rules you are practising under. If they are in Alberta, you are practising medicine in Alberta, and you need standing with the College there. Your Ontario certificate does not travel with the phone call.

Most colleges have carved out narrow exceptions rather than a general permission. Under the CPSA's Virtual Care standard of practice, an out-of-province physician providing virtual care to patients in Alberta must be registered on the Telemedicine Register. A physician without a valid and active CPSA practice permit may provide virtual care to a patient located in Alberta only in limited circumstances: where the care sought is not readily available in Alberta, such as specialty care; to provide follow-up or continuity of care where an established physician-patient relationship exists; or for emergency assessment or treatment where no other options are available. Those are exceptions, not a workaround.

A second requirement catches virtual-first operations. In British Columbia, Alberta and Quebec, an out-of-province physician needs a formal affiliation with a local in-person clinic, so a timely in-person assessment can be arranged if circumstances change. You cannot build a practice on the assumption that every problem stays virtual. Demand is not the constraint anywhere in this system, as health care adding more jobs than every other sector combined makes plain.

Are you inside the province when you bill?

This is the one people miss, because it feels like it should not matter. Whether you are inside the province when you bill changes whether the service is payable at all, and the rule is not the same everywhere. Ontario is strict. For a virtual service to be insured and payable under OHIP, both the patient and the physician must be located in Ontario at the time the service is rendered, under section 37.1 of Regulation 552 of the Health Insurance Act. Take the same call from a hotel in Montreal and the service is not payable, even though the patient, your licence and your obligations are unchanged.

Alberta's regulator takes a more permissive view of the clinical question. The CPSA has said that providing virtual care while you are out of the province or country is acceptable as long as in-person care can be arranged when necessary, with the expectation that you arrange it in a timeframe appropriate to the urgency. That is a practice-standard answer, not a payment answer. Confirm the billing position with Alberta Health Care Insurance Plan or the Alberta Medical Association before you assume the codes follow you, and confirm your liability protection separately, because those are two different coverage questions and one does not imply the other.

Who actually pays for the visit?

Who actually pays is where a common and expensive assumption lives. For an out-of-province patient seen in person, reciprocal billing is the mechanism. Every province except Quebec participates in the interprovincial reciprocal billing agreement for physician services, so you submit through your own plan using the patient's home province health number and the home plan settles it.

That mechanism does not extend to virtual care in Ontario. The Ministry's own bulletin is explicit that virtual care services are not eligible for submission through Reciprocal Medical Billing, and RMB claims carrying a K300A or K301A modality indicator will be rejected to the provider's error report. If your mental model is that reciprocal billing covers an out-of-province patient regardless of modality, that model is producing rejections. Check this one before you check anything else in this article.

Quebec is the other hole in the floor. Quebec does not participate in reciprocal billing for physician services at all, so a Quebec patient is a direct-pay patient. Your only real option is to bill them and tell them to seek reimbursement from RAMQ, which they may or may not receive. Decide your policy on Quebec patients in advance rather than at the front desk. And note that virtual services to patients outside your province are generally not eligible for geographic premiums, so do not assume the premium travels with the code.

How do Ontario's two tiers actually work?

Ontario's two tiers are worth understanding in detail even if you practise elsewhere, because the structure is what other provinces get compared against. Since 1 December 2022, Ontario splits virtual services into Comprehensive and Limited categories. Comprehensive applies where an existing or ongoing patient-physician relationship exists, which the Schedule defines as the patient being enrolled with you or another physician in your group, or having been seen in person in the preceding 24 months. Limited applies where it does not, and it pays substantially less for the same clinical work.

The modality difference is precise rather than vague. Comprehensive services rendered by video are payable at the equivalent in-person fee, while telephone pays 85 percent of it, except for K007, K005, K197 and K198, which pay 95 percent. Limited services rendered outside a relationship use their own codes: A101A for video and A102A for telephone.

That relationship requirement is the single biggest driver of revenue difference in Ontario virtual care, and it is worth auditing. If you are seeing unattached patients virtually and billing as though a relationship exists, you have a problem. If a relationship does exist and you are defaulting to limited codes, you are leaving money behind. Some codes also carry their own history requirement on top of that: a virtual K030A requires a preceding in-person K030A within the previous year, and without an in-person encounter in the preceding twelve months, an A007A would be the eligible code instead.

Which traps are worth checking this week?

Three, and they are the traps worth checking this week because each produces silent leakage rather than an obvious error. First, medical appropriateness is a payment condition rather than a judgement made after the fact. Virtual services are not eligible for payment where it is not medically appropriate to provide them without a direct physical encounter. The Ministry's own worked example is a child with a bead possibly in the ear, seen by a physician with no existing relationship, where otoscopy is required. The physician correctly redirects to in-person care and no virtual service is payable at all. If the visit could not properly be completed virtually, there is nothing to bill.

Second, video carries a technology requirement. In Ontario, video services must be performed using a verified virtual visit solution from Ontario Health's list. A general-purpose video tool that is fine for a team meeting is not automatically fine for an insured visit.

Third, modality indicators. Ontario uses K300A for video and K301A for telephone alongside the service code, and claims missing the indicator are a common and avoidable rejection. One nuance the summaries usually drop: the indicators are required for Comprehensive services, and the Limited codes A101A and A102A do not require them, though a claim carrying one will still be adjudicated. Knowing which rule applies to which tier prevents both rejections and unnecessary resubmissions.

What should you do on Monday?

What to do on Monday is write down three answers once and give them to whoever does your billing. Which provinces are we licensed in, and therefore which patient locations can we accept? What is our rule about physicians billing while physically outside the province, and does it match that province's rule rather than our assumption? What happens when a Quebec patient books, and who at the front desk knows that?

Then pull one month of virtual claims and check three things: that the comprehensive and limited split matches the actual relationships, that every video claim carries the right modality indicator and used a verified platform, and that no out-of-province virtual service went out through reciprocal billing. Most clinics find at least one pattern of leakage in that sample. None of virtual care billing across provinces is complicated once the three questions are separated. It is only confusing because the rules sit in three different places and nobody publishes them together.

It is worth remembering why this matters beyond the revenue line. Structural changes are moving around you, including Alberta letting doctors apply to work in both public and private care, and a Calgary clinic cutting a specialist wait from 18 months to six weeks shows what pathway redesign does when someone actually does it.

It is also worth knowing what your patients are reading before they reach you, since how they get care without a family doctor and what they expect a walk-in visit to cover shape who books with you and what they arrive expecting.

What else do clinics ask about this?

Can I bill OHIP from outside Ontario?

No. Section 37.1 of Regulation 552 requires both the patient and the physician to be physically located in Ontario at the time the service is rendered for it to be insured and payable. Your licence and your professional obligations are unaffected by where you are sitting, but the payability of the claim is not.

Does reciprocal billing cover virtual visits?

Not in Ontario. The Ministry states that virtual care services are not eligible for submission through Reciprocal Medical Billing, and RMB claims submitted with a K300A or K301A modality indicator will be rejected and returned to the provider's error report. Reciprocal billing remains the mechanism for out-of-province patients seen in person.

What separates a Limited from a Comprehensive service?

The existence of an ongoing patient-physician relationship, which the Schedule defines as the patient being enrolled with you or another physician in your group, or having been seen in person within the preceding 24 months. Comprehensive pays the in-person fee for video and 85 percent for telephone. Limited uses separate codes and pays considerably less.

Do I always need a modality indicator?

For Comprehensive virtual services, yes, and a missing indicator is a routine rejection. K300A identifies video and K301A identifies telephone. The Limited codes A101A and A102A do not require an indicator, although a claim that includes one will still be adjudicated for payment where otherwise eligible.

Can I see an out-of-province patient virtually at all?

It depends on the patient's province, not yours. Several colleges require registration on a telemedicine register or a formal affiliation with a local in-person clinic, and permit unregistered out-of-province care only in narrow circumstances. Confirm the receiving college's rules before the appointment, and confirm your liability coverage separately.

Sources: Ontario Ministry of Health EPC billing briefs on virtual care (comprehensive and limited, terms and conditions, case-based examples); Ministry INFOBulletin on virtual health care (reciprocal billing); CPSA Virtual Care standard of practice; Fasken, on cross-province telemedicine requirements. Verify against the current Schedule of Benefits before changing any billing practice.

This article is general information for health professionals and not billing, legal or clinical advice. Payment rules change, and the current Schedule of Benefits and your college's standards govern. For a medical emergency, call 911.

If you want virtual and in-person availability visible to patients in one place, with real wait times and direct booking, you can list your practice on Medimap or browse the Medimap Health Hub for what patients are reading before they book.