How is Botox treatment financially viable under Medicare? The top billing family doctors in Canada should be losing money on it!

[-JAG-]

In some provinces (Alberta and Ontario to be specific), Botox is an insured service when used to treat conditions such as chronic migraines and spasticity.

This usually involves 10+ injections, but the procedure is relatively short and, because it isn’t targeted like a nerve block, doesn’t seem to take much skill. (American YouTube guides show nurses doing it in 5-10 minutes)

At a glance, the codes seem very high for such a straight forward procedure. In Alberta, including the injections, tray fee and visit, you’re looking at a bit over 150$. This is about the same as you get in Ontario.

Googling the names and reviews of the two highest billing family doctors in Ontario show that they both seem to have a significant portion of their practice around this. 
 

However, the math just doesn’t check out. A standard round of injections uses around 155 units of Botox. Botox wholesaled at around 6$ a unit minimum form what I’ve seen. It’s therefore no surprise that in the states doctors bill patients’ private insurance thousands of dollars for this procedures. Also, it’s not like you can just go down the street and by off brand botulinum A, so no way to cut costs.

What gives? Any additional codes/fees that I’m missing here? Sure some doctors are billing in excess of 3.5 million a year with this but they must be spending way more than that on Botox, no? Or are they giving REALLY low doses and banking on the placebo effect taking over?

Are there special provisions for situations like these? For example, in Quebec, when physicians provide prohibitively expensive services, they sometimes sign special agreements with the RAMQ to cover the costs. An example of this was when the ophthalmology department of a large regional hospital was shut down for a few years for renovation. The ophthalmologists got a few million from the RAMQ and were able to bill specially agreed upon codes that were higher than the ones in the provincial fee schedule due to the extreme costs of basically building an eye hospital from the ground up. (This became a huge fraud case later but that’s a story for another time) Is there something similar in Ontario/Alberta? The closest thing I can think of is OHIP reimbursing OB/GYN’s for their extremely expensive (75k+) CMPA dues.

 

[MedicineLCS]

Not a Doc but I have some personal experience here. 

Short answer is the patient provides the Botox, so you're being paid $150 to do a relatively short procedure (which can be even more efficient if a nurse helps). Docs will also stack "Botox days" for even more efficiency. Add in the need to return for the next round and it's quite lucrative (as while as effective in some cases). 

There is also a "generic" botox equivalent I've seen before, I'm not sure what its called or what the cost involved would be. 

[-JAG-]

1 hour ago, MedicineLCS said:

Not a Doc but I have some personal experience here. 

Short answer is the patient provides the Botox, so you're being paid $150 to do a relatively short procedure (which can be even more efficient if a nurse helps). Docs will also stack "Botox days" for even more efficiency. Add in the need to return for the next round and it's quite lucrative (as while as effective in some cases). 

There is also a "generic" botox equivalent I've seen before, I'm not sure what its called or what the cost involved would be. 

Xeomin is, to my knowledge, the only approved generic in Canada, but still something like 5$ a unit. Interesting that the patient provides the Botox (I’m assuming through their private insurance? I doubt most Canadians can afford do drop 3-4K a year on this) Must be the only time patients have to provide the material for an insured service. I’ll dig deeper into the OHIP fee schedule and see if anything about this is mentioned there. Thanks for the insight.

Edit: looking at the UHN website, there is a special category for “payment” under the procedure, where they say that the physician will discuss it with you... interesting 

Second edit: Similar wording on a cerebral palsy site. It’s covered under special circumstances by OHIP+, if not by private insurance or “alternate funding”

[MedicineLCS]

In my (limited) experience some nicer plans will cover it, but some people will pay out of pocket. It's hard to overstate the impact of chronic migraines on someone. 

It is a definite health equity issue, where the wealthier and better served by plans do benefit. Unfortunately I can see the "Province pays for Botox" headlines and ensuing outrage scaring away admin. 

[crazybananas411]

From personal experience in Ontario: The botox itself is covered for patients who don't have private insurance and are eligible for OHIP+. Physicians charge patients the injection fee ($150), which is not covered by OHIP or private insurance. Doctors may also bill OHIP as well, that I don't know.

[-JAG-]

7 hours ago, crazybananas411 said:

From personal experience in Ontario: The botox itself is covered for patients who don't have private insurance and are eligible for OHIP+. Physicians charge patients the injection fee ($150), which is not covered by OHIP or private insurance. Doctors may also bill OHIP as well, that I don't know.

I was under the impression that the injection fee was covered. After all, it’s in the fee schedule and there aren’t any special governing rules concerning the code that I’m aware of other than the fact it could only be billed every 12 weeks. The top billing family doctors who specialize in Botox pain treatment are billing OHIP, not the patient. We wouldn’t know what they were making if the patient was paying, or am I not seeing something important? 

[Aetherus]

I’ve seen certain physicians get patients with coverage for Botox acquire the bottle and then they keep the bottle and offer the Botox free of charge for patients who don’t have insurance coverage for it. This way everyone gets it for free.

[crazybananas411]

Interesting...I've had it for chronic migraine from 4 different doctors and they all made me pay 

They were all neurologists not family docs though, maybe that makes a difference?

[-JAG-]

5 hours ago, Aetherus said:

I’ve seen certain physicians get patients with coverage for Botox acquire the bottle and then they keep the bottle and offer the Botox free of charge for patients who don’t have insurance coverage for it. This way everyone gets it for free.

Isn’t that insurance fraud?

[Aetherus]

8 hours ago, -JAG- said:

Isn’t that insurance fraud?

How? Insurance pays for the whole bottle for each treatment. The remainder of the bottle would be thrown out otherwise. But instead they use it for other patients that are uninsured.

[Snowmen]

In all the spasticity clinics I've been in (quite a few), the doctor sees the patient for a first evaluation and gives him a prescription for Botox. Patient goes to the pharmacy, picks up Botox and brings it to a second appointment where the physician injects it and bills the government for the service.

Just wanted to add that it isn't a simple procedure like you mentioned. The evaluation is very important to make sure you're not injecting hundreds of dollars of drugs into the wrong muscle with no functional benefit. On top of that, the procedure has to be guided with at least EMG while U/S guidance is slowly becoming the gold standard.

[-JAG-]

14 hours ago, Aetherus said:

How? Insurance pays for the whole bottle for each treatment. The remainder of the bottle would be thrown out otherwise. But instead they use it for other patients that are uninsured.

I see, thanks for clarifying!

[-JAG-]

12 hours ago, Snowmen said:

In all the spasticity clinics I've been in (quite a few), the doctor sees the patient for a first evaluation and gives him a prescription for Botox. Patient goes to the pharmacy, picks up Botox and brings it to a second appointment where the physician injects it and bills the government for the service.

Just wanted to add that it isn't a simple procedure like you mentioned. The evaluation is very important to make sure you're not injecting hundreds of dollars of drugs into the wrong muscle with no functional benefit. On top of that, the procedure has to be guided with at least EMG while U/S guidance is slowly becoming the gold standard.

I’ve seen that for spasticity it’s usually ultrasound guided, but often for migraines, it’s more of a shotgun approach. I do think you can bill for ultrasound guidance in Ontario, something like 28$. 

[ArdentMed]

Based on the posts in this thread, it seems that the patient brings the Botox that they were  prescribed from the first visit to the second visit. So the procedure alone is billed $150, not the Botox. 

[HaroldChung]

It seems to me that you can't save money on procedures that involve injections. That's why you should choose a doctor not on who is cheaper but on who is more qualified. In fact, you are injected into the skin, where the nerves and blood vessels pass through. If you don't do it correctly, you can injure the nerve. So when I want to get Botox injections or a small facelift, I go to a plastic surgeon. It might be helpful for you to learn about https://www.realself.com as well. Now I go to a cosmetologist regularly to maintain the results.

[Edict]

On 3/13/2020 at 10:28 PM, Aetherus said:

How? Insurance pays for the whole bottle for each treatment. The remainder of the bottle would be thrown out otherwise. But instead they use it for other patients that are uninsured.

Woa is that ethical, using previously opened botox? If you disclosed it sure but how many people would disclose that, seems weird. 

[hero147]

2 hours ago, Edict said:

Woa is that ethical, using previously opened botox? If you disclosed it sure but how many people would disclose that, seems weird. 

As long as the needles entering the bottle of botox are clean, it shouldn't pose a health risk to future patients unless the botox goes bad after a couple hours of being opened. Many drugs are stored in multi-use vials including the covid vaccines or else the waste would be astronomical if all bottles were thrown out after use.