FHO+ Time-Based Billing: The Complete Guide for Ontario Family Physicians

FHO+ Time-Based Billing: The Complete Documentation and Compliance Guide for Ontario Family Physicians

By Marc & Jason Lacroix | OpsMed.ca | Published March 2026

This article is for general informational purposes only and does not constitute legal, accounting, or billing advice. Physicians should consult the OMA, their billing agent, or legal counsel for guidance specific to their practice.

Ontario's FHO+ model is set to launch April 1, 2026, introducing time-based billing at $80/hour in 15-minute increments for eligible categories, according to OMA guidance available as of March 2026. Current FHO physicians will auto-transition to FHO+ on April 1 — no action is needed unless opting out, though FHO leads must sign the updated contract by March 31. Many physicians are still asking what to track, how to document it, and what the audit risks may look like. This guide summarizes the core published requirements, maps the billing codes to an illustrative physician workflow, and identifies the compliance pitfalls that could affect your practice. Whether you're looking for the quick-reference card to tape to your monitor or the deep regulatory detail, it's all here. For a quick overview of what FHO+ time-based billing means for your clinic, see our blog summary.

A note on sources: This guide distinguishes between confirmed rules (sourced from official OMA/MOHLTC publications), interpretive guidance (reasonable inferences from existing frameworks), and open questions (areas where implementation details remain unresolved). These distinctions are noted throughout and summarized in the Coverage and Limitations section.

Critical code correction: Some early materials created confusion about Q310/Q311 mapping. Per confirmed OMA guidance, Q310 = Direct Patient Care ($80/hr) and Q311 = Direct Telephone Care, Not in Office ($68/hr). This guide uses these codes throughout.

Table of Contents

Quick Reference Card — Tape to Your Monitor on April 1

FHO+ HOURLY RATE — DAILY QUICK REFERENCE

THE FOUR CODES:

Code What Rate
Q310 Direct care (in-person, video, phone IN office) $80/hr
Q311 Phone care when OUT of office $68/hr
Q312 Indirect care (charting, labs, referrals, conferences) $80/hr
Q313 Clinical admin (screenings, QI, EMR updates) $80/hr

DAILY MUST-DO:

  1. Track total hours in each category (no start/stop times needed)
  2. Write a brief activity description for Q312 and Q313 entries
  3. Keep total under 14 hours/day

ROUNDING: 8+ minutes of remainder → rounds up to next 15-minute unit

CAPS TO MONITOR:

  • Q312 + Q313 combined ≤ 25% of total hours (28-day rolling)
  • Q313 alone ≤ 5% of Q310+Q311+Q312 hours (28-day rolling)
  • Monthly max: approximately 257 hours in a 30-day month (based on 240-hour-per-28-day cap)

REMEMBER:

  • Shadow billing continues — you must still shadow bill for eligible services per OMA guidance
  • Hourly rate is on top of capitation + shadow billing + premiums
  • Only YOUR time counts (not nurses, NPs, staff)
  • Only eligible work related to rostered patients qualifies
  • FHO+ hourly rate claims follow standard OHIP stale-date rules. While the standard stale date for most OHIP claims is three months (since April 1, 2023), physicians should confirm the specific submission window for Q310–Q313 codes with their billing service, as these are new codes and implementation details may evolve (see Section 1 for details)
  • Video from home = $80/hr (Q310). Phone from home = $68/hr (Q311). Charting from home = $80/hr (Q312).

DON'T BILL: Hospital services, non-rostered patients, delegated tasks, uninsured services, time spent logging your hours

YEAR 1 CAUTION: OMA guidance indicates the 25%/5% ratio caps may not be system-enforced until April 2027. Physicians should monitor these ratios closely, as overpayments may be subject to later reconciliation. Track your own ratios from Day 1.

1. Exact FHO+ Time-Based Billing Requirements

The Four Billable Fee Codes and What Qualifies Under Each

The FHO+ (Family Health Organization) hourly rate creates four distinct Ontario Health Insurance Plan (OHIP) billing codes, each paid in 15-minute increments and cumulated daily. The rate structure is simpler than many physicians expect — only one scenario triggers a reduced rate.

Code Category Rate Location Rule
Q310 Direct Patient Care (in-person, video, telephone in-office) $80/hr Full rate regardless of location for in-person/video; telephone from IN office also $80/hr
Q311 Direct Telephone Care — Not in Office $68/hr (85%) Applies ONLY when physician provides telephone care while physically out of clinic
Q312 Indirect Patient Care $80/hr Same rate in-office or out-of-office
Q313 Clinical Administration $80/hr Same rate in-office or out-of-office

Q310 — Direct Patient Care covers all time spent personally delivering insured clinical services to rostered patients: in-person encounters, video visits (from any location), telephone calls made from within the clinic, and clinical teaching done concurrently with patient care. Video-based virtual care from home earns the full $80/hr — only telephone from outside the office is discounted.

Q311 — Telephone Care, Not in Office applies exclusively to telephone-based care when the physician is physically outside their clinic. This is the only scenario that pays $68/hr rather than $80/hr. Video calls from home are NOT Q311 — they qualify as Q310 at full rate.

Q312 — Indirect Patient Care encompasses all patient-specific insured work without direct contact, including:

  • Charting and documentation
  • Preparing referrals and requisitions
  • Completing clinical forms, reports, and medical certificates of death (excluding third-party requests)
  • Chart reviews (labs, imaging, consult notes)
  • Conferencing with other physicians and healthcare professionals about specific patients
  • Family conferences and pre/post-care communication with patients or representatives
  • Clinical research for a particular patient
  • Patient-specific clinical teaching to learners arising from direct patient care

Q313 — Clinical Administration covers non-patient-specific tasks requiring physician expertise: proactive patient management such as screening programs and chronic disease management initiatives; electronic medical record (EMR) updates requiring physician expertise; quality improvement initiatives; and clinic-based implementation work such as change management for digital health tool adoption. It explicitly excludes non-clinical administrative tasks (HR, finance, supply ordering) and time spent documenting your hours.

Quick Decision Tree: Which Code Applies?

Is this direct patient interaction (in-person, video, or phone)?
├── YES → Are you on the telephone AND physically outside the clinic?
│   ├── YES → Q311 ($68/hr)
│   └── NO → Q310 ($80/hr)
└── NO → Is the work related to a SPECIFIC patient?
    ├── YES → Q312 ($80/hr) — Indirect Patient Care
    └── NO → Does the work require your clinical expertise?
        ├── YES → Q313 ($80/hr) — Clinical Administration
        └── NO → NOT BILLABLE (HR, finance, supply ordering, logging hours)

Activities NOT Billable Under the Hourly Rate

The exclusion list is equally important: care provided in emergency departments or hospitals; care delivered by team members (delegated injections, nurse-administered tasks); care to non-rostered patients; uninsured services (third-party forms, cosmetic procedures); travel time for home visits; non-clinical administrative tasks; and time spent logging hours. In-hospital services are now paid at 100% FFS as an out-of-basket benefit — a significant change, but outside the hourly rate. Physicians should confirm eligible hospital service types with OMA guidance, as nuances may apply by service type and site.

The 15-Minute Increment and Rounding Rules

Time is calculated cumulatively across the day for each category, not per-encounter. Partial increments of 8 minutes or more round up to a full 15-minute unit; 7 minutes or fewer are dropped.

A physician who logs 37 minutes of direct care bills 2 units (30 minutes); 38 minutes bills 3 units (45 minutes). This rounding is applied per-category on daily totals, making precise per-encounter timing unnecessary. [Source: OMA FHO+ Hourly Rate page]

Daily and Monthly Caps with Year 1 Enforcement Nuances

The 14-hour daily maximum is a hard cap enforced by the Ministry billing system from Day 1. The monthly cap is 240 hours per 28 days, prorated by calendar month — for example, April 2026 (30 days) allows approximately 257.1 hours maximum; a 31-day month allows approximately 265.7 hours.

Two ratio caps constrain indirect and administrative billing:

  • Combined indirect + clinical administration cannot exceed 25% of total billable hours (measured over 28 consecutive days)
  • Clinical administration alone cannot exceed 5% of combined direct + indirect care hours (over 28 days)
  • Practical interpretation: for every 3 hours of direct care, a physician can bill approximately 1 hour of indirect + administration combined

Year 1 enforcement is partial — and this creates a compliance risk. In Year 1 (April 2026–March 2027), only the daily and monthly hour caps are programmed into the Ministry system. The 25%/5% ratio caps will reportedly not be system-enforced until Year 2. However, OMA guidance indicates that if a physician exceeds these ratios in Year 1, they will be paid initially and the Ministry will reconcile overpayments at a later date.

Additionally, in Year 1, if a claim submission would push total monthly hours above the cap, OMA guidance indicates the entire claim is rejected — not just the excess hours. This reportedly changes in Year 2, where only the overage is rejected. Given the financial significance of this distinction, physicians should confirm this behavior with their billing agent or the OMA. [Source: OMA FHO+ Hourly Rate page, March 2026 update]

Time Tracking: Per-Patient or Per-Category?

Based on OMA guidance available as of March 2026, documentation for these codes does not require patient-level time tracking. Physicians record only the total daily duration for each of the four categories. Start and stop times are not required — only daily totals.

For Q312 and Q313, a daily list of activities must accompany the time entry, but this list does not need to break down time per activity or per patient. The OMA's own example: "April 1 – Indirect Patient Care – one hour – chart reviews, sent referrals, reviewed lab results." [Source: OMA FHO+ Hourly Rate page]

How Time-Based Billing Interacts with Capitation and Shadow Billing

The hourly rate is purely additive. It does not replace capitation, shadow billing, or any other payment stream — it supplements all of them. The full FHO+ compensation stack is:

  1. Base capitation payments (unchanged)
  2. Comprehensive care capitation (unchanged)
  3. Shadow billing at 30% (increased from 19.4%) for most in-basket services; 50% for select in-basket procedures — physicians should consult the updated PSA fee schedule for specific service categories
  4. Hourly rate (Q310–Q313) — NEW, billed on top of everything
  5. After-hours premiums at 50% (increased from 30%)
  6. Patient attachment bonuses: Q053 increased to $500 (from $350); new Q054 (mother/newborn) at $350; additional codes Q055 (multiple births) and Q056 (Health Care Connect referrals); per-patient bonuses of $100–$180 (established patients) and $150–$270 (new graduates)
  7. Preventive care bonuses (continuing)
  8. Group Management Leadership Payment at $5/patient (up to $125,000) — eligibility thresholds and group-structure rules may apply
  9. Out-of-basket FFS at 100%
  10. Hospital services at 100% FFS (previously shadow billed)

Eliminated: Access bonus, CCM fee, negation system — all replaced by the hourly rate and continuity of care measure.

Also note: FHO+ lowers the minimum group size from 3 to 2 physicians and offers co-location flexibility, making FHO formation easier for smaller practices.

Physicians must continue to shadow bill alongside the hourly rate. Shadow billing remains required for eligible services under OMA guidance. OMA guidance suggests that a physician may need roughly 12 hours/week of hourly-rate billing (over 46 working weeks) to offset the removal of the access bonus and CCM fee, though the exact figure will vary significantly by practice. Hours above that threshold represent net new revenue.

For a broader look at how this fits within the full FHO+ compensation framework, see our FHO+ Billing Guide.

Submission Deadlines and Stale-Date Rules

FHO+ hourly rate claims follow standard OHIP stale-date rules. While the standard stale date for most OHIP claims is three months (since April 1, 2023), physicians should confirm the specific submission window for Q310–Q313 codes with their billing service, as these are new codes and implementation details may evolve. Note: Do not assume the standard three-month window automatically applies — confirm timelines before delaying submissions. In Year 1, claims are paid on the regular OHIP payment cycle.

In Year 2 (starting April 2027), hourly rate claims will shift to whole-month payment similar to capitation — billings submitted in one month are paid in full the following month (e.g., April billings paid in May).

The Continuity of Care Measure Replaces Access Bonus and Negation

The 75% continuity threshold is measured quarterly per individual physician roster. The numerator includes in-basket visits by the rostering physician, any physician in the same FHO group, contracted locums, and specific acceptable providers (GP focused practice, HIV/COE, certain ED/hospital codes).

The denominator includes all in-basket visits to any family physician (specialty '00') by your rostered patients — including walk-in clinics. If a physician falls below 75% for two related quarters, 15% of capitation from the first failing quarter is deducted from a future payment. First failure triggers notification only.

Approximately 86% of current FHO physicians already meet this threshold, according to OMA analysis. [Source: OMA Continuity of Care page]

Important caveat: The exact definition of "visit" for continuity purposes has not been fully settled — the OMA states details "will be determined through implementation." Physicians should not rely solely on simplified summaries and should monitor official updates as they are released. See our Unresolved Questions section for more detail.

2. Documentation and Audit Requirements

What Records Physicians Must Maintain

The OMA specifies two documentation obligations, and they are deliberately minimal:

  1. Daily totals of time in each of the four categories (Q310, Q311, Q312, Q313)
  2. Daily activity descriptions for indirect care (Q312) and clinical administration (Q313) — a brief narrative list of what was done

No start/stop times are required. No patient-level documentation is required. No specific format is mandated — "You are free to document this information wherever you choose, using whatever method works best for you," the OMA states explicitly. Paper logs, spreadsheets, EMR entries, or dedicated software all satisfy the requirement.

The OMA and OntarioMD (OMD) are developing optional EMR-based tools, with step-by-step EMR instructions published at omdeducates.com/fho-hourlyrate/. An FHO+ hourly rate reference guide PDF is available on the OMA website.

What "The Ministry May Request Records" Means in Practice

The OMA states:

"Similar to documentation for other insured services, the ministry may request copies of your records or other information to demonstrate the work billed for a given day."

Based on the existing OHIP post-payment audit framework under Health Insurance Act Section 18, the following processes apply:

How audits are initiated:

  • The Ministry can initiate a post-payment audit for any physician at any time
  • Audit triggers may include tips or complaints, referrals from government programs, recurring billing irregularities, and data analytics

What happens during an audit:

  • The Ministry requests medical records and practice information in writing
  • In rare cases, an on-site reviewer may collect records
  • OHIP can obtain a court order to compel production if a physician is non-responsive
  • Records review typically takes 3–6 months from receipt

Your rights during an audit:

  • You have the right to respond to any audit findings before a decision is made
  • You may wish to consult with the OMA, CMPA, or legal counsel if audited
  • Contemporaneous records carry significantly more weight than records reconstructed after the fact

The Ontario Auditor General has previously criticized the Ministry for relying on reactive oversight rather than broader analytics-based detection. This could increase scrutiny of unusual billing patterns under FHO+, particularly given the novel nature of time-based claims. [Sources: Ontario Auditor General reports; Globe and Mail reporting]

Acceptable Versus Insufficient Documentation

Acceptable (OMA's own examples):

"April 1 – Indirect Patient Care – reviewed charts, sent referrals, reviewed lab results"

"April 1 – Indirect Patient Care – one hour – chart reviews"

Likely insufficient (based on EPC precedent and audit standards):

  • "Did admin work" — too vague
  • Aggregate monthly totals only, without daily breakdown
  • Identical entries repeated daily with zero variation — this is a major audit flag in every jurisdiction that uses time-based billing
  • No documentation at all — highest audit risk

A note on AI scribes and automated templates: Physicians using AI-assisted documentation tools should manually review generated notes. "Cloned" or template-generated entries that appear identical across dates may trigger the same audit flags as cut-and-paste documentation in other jurisdictions.

Important distinction from traditional time-based codes: The EPC Billing Brief on time-based services requires start and stop times on the patient's permanent medical record for K-codes, counseling, and psychiatry billing. FHO+ hourly rate codes are fundamentally different — they require only daily totals, not start/stop times, and not patient-level records. This makes FHO+ auditing entirely novel territory for OHIP auditors. No EPC Billing Brief has been issued for Q310–Q313 as of March 2026.

Record Retention Period

No FHO+-specific retention guidance exists. Based on converging standards:

  • CPSO requires 10 years from the date of the last record entry, or 10 years after the day a minor patient reaches (or would have reached) 18 years of age — whichever is later
  • CMPA recommends 10 years minimum (15 years prudent)
  • OHIP post-payment audits are limited to billings within a 24-month period commenced no more than 5 years before the General Manager's review request
  • The Ontario Limitations Act imposes a 15-year ultimate limitation period

The safe standard is 10 years minimum; 15 years is prudent. Family physicians with pediatric patients should pay particular attention to the minor-patient retention rule, which can extend the obligation significantly.

Audit Jurisdiction and Enforcement

The Medical Review Committee (MRC) was dissolved around 2015–2016 and replaced by the current enforcement structure:

  • Provider Audit and Adjudications Unit (PAU) conducts the audit
  • General Manager of OHIP forms opinion on audit outcome
  • Health Services Appeal and Review Board (HSARB) serves as independent tribunal for contested cases
  • The Education and Prevention Committee (EPC) has educational jurisdiction only (billing briefs, guidance), not enforcement
  • HSARB can order repayment (limited to 24-month billing period, no more than 5 years back), billing suspension, and can use statistical sampling/extrapolation

Recent Enforcement Cases Signal Audit Severity

Recent Ontario audit and billing enforcement cases demonstrate that extreme time-based billing patterns and poor documentation can lead to serious consequences. Outcomes in recent cases have included:

  • Significant repayment orders — in one recent case, HSARB ordered a clawback exceeding $600,000 (partially overturned on procedural grounds by Divisional Court, with records deficiencies central to the case)
  • Criminal convictions under the Health Insurance Act for billing time-based codes for implausible hours (e.g., multiple service dates exceeding 18–24 hours in a single day)
  • Billing suspensions of 12 months or longer and multi-year supervised billing periods

These cases demonstrate that billing near daily caps consistently will draw scrutiny. The Ministry audits only a small proportion of physicians each year, but repayment exposure in individual cases can be significant.

For more context on the administrative burden driving the need for better billing tools, see our Ontario Physician Administrative Burden research.

3. A Typical FHO+ Physician's Day: Capturing Previously Unbilled Time

Morning Through Evening — Every Billable Category Switch Mapped

The following illustrative workflow map shows how a physician's day may involve frequent billing category transitions and several hours of work that may now be compensable under FHO+. These transitions represent time that was entirely unbilled under the old FHO model.

7:30–8:30 AM — Pre-clinic inbox review → Q312 ($80/hr)

Reviewing overnight faxes, lab results from OLIS, Hospital Report Manager discharge summaries, patient portal messages, and triaging inbox items. All patient-specific — clearly Q312 Indirect Patient Care. Previously uncompensated; under FHO+, this time is billable at $80/hr.

8:30 AM–12:00 PM — Morning appointments → Q310 + shadow billing

8–10 patient encounters. Each face-to-face minute is Q310 Direct Patient Care at $80/hr, with simultaneous shadow billing of the visit code (A001, A003, A007) at 30%. Between appointments, every moment of charting, chart review for the next patient, or lab result review switches to Q312. If the physician takes a phone call from a rostered patient while in-clinic, this remains Q310 at the full rate. The micro-transitions between Q310 and Q312 may occur many times in a morning session alone.

12:00–12:30 PM — Midday charting catch-up → Q312 ($80/hr)

Completing notes, reviewing pending results. Previously uncompensated; under FHO+, billable at up to $40 for this half-hour.

12:30–1:00 PM — Staff meeting → Q313 if clinical; NOT billable if administrative

Peer discussion about quality improvement protocols or chronic disease screening: Q313 Clinical Administration. Meeting about HR, staffing, or finances: explicitly excluded. Personal lunch: not billable.

1:00–4:30 PM — Afternoon appointments → Q310 + shadow billing

Same pattern as morning — 8–10 encounters with repeated transitions between Q310 (face time) and Q312 (between-appointment charting).

4:30–5:30 PM — End-of-day referrals, results, callbacks → Q312 ($80/hr)

Processing referrals (Q312, not Q313 — referrals are patient-specific), reviewing lab results, calling patients about results. Referral processing is explicitly listed under Q312 as "preparing referrals and requisitions." Previously uncompensated; under FHO+, billable at $80/hr.

5:30–6:00 PM — Population health review → Q313 ($80/hr)

Reviewing chronic disease management panels, screening gap reports. Previously uncompensated; under FHO+, billable at up to $40 for this half-hour, constrained by the 5% cap.

Evening — Home documentation → Q312 ($80/hr); phone calls from home → Q311 ($68/hr)

Charting from home: Q312 at full rate (indirect care rate is location-independent). Telephone calls to rostered patients from home: Q311 at $68/hr. Video calls from home: Q310 at $80/hr (the discount applies ONLY to telephone when out-of-office). Previously uncompensated; under FHO+, potentially billable at $80–$160 depending on time spent.

Illustrative Revenue Impact of Capturing Previously Unbilled Time

The following table provides illustrative estimates only — actual revenue will vary significantly by practice type, patient panel, and workflow. These figures are based on the confirmed $80/hr rate applied to time ranges that align with published data on physician administrative workload (e.g., CMA National Physician Health Survey data on non-clinical time).

Activity Daily Hours (Est.) Daily Revenue (Est.) Annual Estimate (207 clinic days)
Morning inbox/fax review 1.0 hr $80 $16,560
Between-appointment charting 1.0 hr $80 $16,560
Midday catch-up 0.5 hr $40 $8,280
End-of-day referrals/results 1.0 hr $80 $16,560
Evening documentation 1.0 hr $80 $16,560
Clinical admin/QI 0.5 hr $40 $8,280
Total newly captured 5.0 hr $400 $82,800

A conservative estimate (capturing only 3 hours/day) yields approximately $49,680/year in new revenue. The moderate estimate (4 hours/day) yields approximately $66,240/year. The 207-clinic-day figure assumes approximately 46 working weeks at 4.5 days per week.

Note: the 25% indirect+admin cap constrains the maximum — a physician billing 7 hours of direct care can bill approximately 2.3 hours of indirect + admin. OMA guidance suggests physicians may need only roughly 12 hours/week of hourly-rate billing to replace the eliminated access bonus and CCM fee, though this figure will vary significantly by practice; everything above that threshold is net new income.

4. What Other Jurisdictions Reveal About Time-Based Billing Risks

British Columbia's LFP Model Is the Closest Precedent

BC launched its Longitudinal Family Physician (LFP) Payment Model on February 1, 2023, with a strikingly similar structure to Ontario's FHO+: three time categories (98010 Direct Care, 98011 Indirect Care, 98012 Clinical Administration), all billed in 15-minute increments at $32.50/increment ($130/hr), with a 14-hour daily cap and a 50-interaction daily maximum.

Critical difference from Ontario: BC requires physicians to record start and end times for each block of time on the billing claim. Ontario requires only daily totals — a significantly lighter documentation burden. BC also uses a generic diagnosis code (L23) for all time claims rather than the actual patient diagnosis.

BC physicians use EMR-integrated billing dashboards (OSCAR, Med Access), Dr.Bill (third-party billing platform with LFP dashboards), and DoctorCare for billing management. BC Family Doctors explicitly recommends recording start/end times for each work day using a daily planner, time management app, or EMR. Claims exceeding typical peer physician hours are flagged for audit. BC's model has been in operation since February 2023 and provides the most directly comparable implementation experience.

Australia's Cautionary Tale About Audit-Driven Under-Billing

Australia's Medicare Benefits Schedule uses time-tiered GP billing across five levels, from Level A (<6 minutes, ~$18 AUD) to Level E (≥60 minutes, ~$152 AUD). Research summarized in The Conversation (drawing on academic survey data) suggests that a significant proportion of Australian GPs may intentionally under-bill due to fear of triggering compliance reviews — a phenomenon that directly undermines the purpose of time-based payment.

Australia's compliance framework includes targeted letters for pattern deviation, formal audits, and the Practitioner Review Program for "inappropriate practice." The "80/20 rule" flags GPs whose billing patterns significantly deviate from peers.

This experience is a cautionary signal: if Ontario's audit framework creates excessive uncertainty, physicians may under-bill and leave revenue on the table, defeating the model's purpose.

The US 2021 E/M Code Changes and Documentation Lessons

Since January 2021, US physicians can select E/M code level based on either Medical Decision Making or Total Time — including non-face-to-face time on the date of encounter (chart review, documentation, care coordination).

Key documentation guidance: record specific total time (not ranges); avoid cut-and-paste generic time statements (these are audit red flags); and note that using identical times across encounters signals automated fabrication rather than actual tracking. In the US, physicians are widely advised that unusual E/M coding patterns, including heavy use of higher-level or time-based coding, may draw payer scrutiny.

Cross-Jurisdictional Lessons for Ontario

  • Embed tracking in clinical workflow: The most successful systems (BC's EMR-integrated LFP billing, US EHR encounter timers) build time tracking into the existing clinical encounter flow. Standalone apps create friction and reduce adoption.
  • Peer benchmarking is the universal audit trigger: BC, Australia, and the US all flag outlier billing patterns relative to peers. Ontario will likely do the same.
  • Prevent template documentation: Identical time entries across dates are major audit flags in every jurisdiction.
  • Build clear safe harbors: Australia's experience shows that ambiguous audit thresholds cause under-billing. Published anonymized peer benchmarks would help Ontario physicians bill with confidence.
  • Cap daily hours explicitly: Both BC and Ontario cap at 14 hours. The existence of a clear upper limit simplifies compliance.

Existing Physician Time-Tracking Tools Across Markets

Tool Jurisdiction Features FHO+ Relevance
Dr.Bill Canada (BC) LFP time code support, automated portal submission, dashboards Moderate — BC-focused, no Ontario FHO+ support
TimeSmart.AI US AI-driven physician timesheet validation against contract terms Moderate — concept applicable, but US Stark Law focus
MediBetter BOSS Australia AI item number suggestion from consult notes Low — different billing model
Toggl Track / Clockify Global General time tracking, APIs, custom categories Adaptable but lacks healthcare/FHO+ specifics
ActivityWatch Global (open-source) Local-first automatic app usage tracking Could complement by detecting EMR usage patterns

As of March 2026, no dedicated FHO+ time-tracking tool is widely available. DoctorCare and Bill Medics offer consulting services but not software products. OMA/OMD tools are in development. This suggests there is still limited published tooling support for FHO+ time tracking in Ontario.

For more on the broader landscape of clinic tools and automation, see our Ontario Clinic Automation Landscape guide.

5. Transition Period Playbook: April Through June 2026

What Physicians Should Do in the Next 10 Days (March 21–31)

Contractual urgency: FHO leads must sign the updated FHO contract by March 31, 2026. Individual physician declarations are due by June 30, but the group agreement deadline is immovable. Not signing could jeopardize the entire group's ability to operate under FHO+.

Automatic transition: Current FHO physicians will auto-transition to FHO+ on April 1, 2026 — no action is needed to enroll. The March 31 deadline applies to the updated group contract signing, not to individual enrollment.

Immediate preparation checklist:

  • Confirm FHO lead has signed or will sign the updated contract by March 31
  • Update EMR billing software to include new fee codes Q310, Q311, Q312, Q313 — contact your vendor immediately if updates haven't been deployed
  • Review OntarioMD's EMR-specific instructions at omdeducates.com/fho-hourlyrate/
  • Set up a daily time tracking system (paper, spreadsheet, or EMR template) with columns for each of the four categories plus an activity description field
  • Build a tracking spreadsheet for the 25%/5% ratio caps on a rolling 28-day basis
  • Watch the March 11 OMA Learns webinar recording on FHO+ billing
  • Download the FHO+ hourly rate reference guide PDF from OMA
  • Use the OMA FHO+ Calculator to model personal income scenarios
  • Brief office staff on new billing codes, documentation requirements, and the elimination of access bonus tracking
  • Stop tracking access bonus and outside-use data — these metrics are eliminated under FHO+

Interim Documentation Approaches That Meet Minimum Requirements

Any of the following meet the OMA's stated requirements:

Paper log (simplest): A lined notebook with five columns — Date | Direct Care (hrs) | Telephone Out-of-Office (hrs) | Indirect Care (hrs + activities) | Clinical Admin (hrs + activities). Write entries at end of each day.

Spreadsheet (recommended minimum): Google Sheet or Excel with the same columns, plus formulas for 15-minute rounding, daily cap tracking, and 28-day rolling ratio calculations. This approach provides searchability and exportability for audits.

EMR encounter note: Create a daily "Time Tracking" note within the EMR system, categorized under each billing code with activity descriptions. This keeps documentation within the existing clinical record system.

Nine Common Billing Pitfalls in Q1

  1. Not tracking from April 1 — the stale-date window (confirm specific timelines with your billing service) means lost days are permanently lost revenue
  2. Over-billing indirect/admin without monitoring ratios — Year 1 pays everything initially but reconciles later
  3. Missing the contract deadline — FHO lead must sign by March 31
  4. Submitting claims that exceed the monthly cap — in Year 1, claims that would push total monthly hours above the cap may be rejected by the billing system. In Year 2, the system will reject only the excess hours rather than the full submission
  5. Confusing in-office vs. out-of-office telephone — Q310 vs. Q311, $80/hr vs. $68/hr
  6. Not updating EMR billing modules — new Q-codes won't be available if the vendor hasn't pushed the update
  7. Continuing to track access bonus metrics — eliminated, wasting effort
  8. Under-billing due to overwhelm — some physicians will simply skip hourly rate billing entirely, potentially forfeiting significant annual revenue
  9. Assuming retrospective documentation is acceptable — while stale-date rules allow delayed submission, fabricating activity descriptions for days not tracked contemporaneously creates audit risk

Can Practices Retroactively Claim if Tracking Starts Late?

Standard OHIP stale-date rules permit delayed submission — but physicians should confirm the specific submission window for Q310–Q313 codes with their billing service, as these are new codes and timelines may differ. However, if a physician didn't track daily totals and activity descriptions on the actual dates, they cannot reliably reconstruct them.

Submitting claims without contemporaneous documentation creates significant audit vulnerability, since the Ministry can request records at any time. The answer: technically possible but practically risky. Start tracking April 1.

6. Ontario EMR Integration, OHIP Billing Software, and the Data Gap Problem

What EMRs Already Capture That Supports Time Tracking

All three major Ontario EMRs (OSCAR Pro, Accuro, PS Suite) already capture appointment schedules with booked start/end times, encounter note timestamps (chart open/save), billing submissions with service dates, inbox/lab result receipt timestamps, prescription and referral creation timestamps, and basic audit trail logging.

This data can serve as proxies for direct care time (appointment-based) and some indirect care activities (chart opens without appointments, lab result reviews, referral creation).

The Critical Data Gap — What EMRs Cannot Provide

Five categories of information essential for FHO+ time tracking are not adequately captured by Ontario EMRs in their current configurations:

  1. Activity categorization — EMRs cannot distinguish between Q312 and Q313 activities. A lab result review (Q312) and a screening panel review (Q313) look identical in the EMR.
  2. Non-EMR work time — Phone calls from personal devices, hallway consultations with colleagues, paper-based form completion, staff meetings.
  3. In-clinic vs. out-of-clinic determination — Critical for distinguishing Q310 ($80/hr) from Q311 ($68/hr) for telephone care. Ontario EMRs do not typically capture physician physical location in a way that would reliably distinguish in-office from out-of-office telephone care for billing purposes.
  4. Precise encounter duration — Booked time ≠ face time. A 15-minute appointment slot may have 10 minutes of patient contact and 5 minutes of documentation.
  5. Narrative activity descriptions — The Ministry requires daily activity descriptions for Q312 and Q313. No EMR auto-generates these.

These gaps define the minimum requirements for any FHO+ time-tracking tool: it must bridge the divide between what EMRs capture automatically and what the OHIP billing model demands.

EMR-Specific Integration Capabilities

Note: The following technical details reflect vendor documentation available as of early 2026. API capabilities, version requirements, and partnership terms change frequently — confirm current details with each vendor before making integration decisions.

OSCAR Pro offers the strongest integration path. It provides a REST API with OAuth 1.0a authentication and a SOAP API for scheduling. Key endpoints include appointment schedules, encounter notes, inbox items, billing submissions, messaging, demographics, and referral/consult requests. OSCAR Pro also supports SMART on FHIR HL7 for standardized integrations. WELL Health (OSCAR Pro's parent) must authorize API access.

Accuro provides a comprehensive REST API with OAuth 2.0, including appointment state-change tracking that captures transitions (arrival, seen, completed) with timestamps — highly valuable for timing encounters. Access requires a formal agreement with QHR Technologies, sandbox testing, and certification. The API supports appointments, demographics, labs, documents, medications, tasks, and messaging.

PS Suite has the most restrictive integration model. The TELUS proprietary API has documented limitations — some data elements are inaccessible, requiring workarounds through the Ocean Toolbar plugin or custom forms (.cfm files). Third-party access requires a signed partnership agreement with TELUS Health. OceanMD (CognisantMD) serves as primary middleware. Integration is possible but requires more workaround engineering than OSCAR or Accuro.

Privacy and Data Security Considerations

Any tool that integrates with EMR data or tracks physician activities must comply with Ontario's Personal Health Information Protection Act (PHIPA). Key considerations include:

  • Data residency: Patient-identifiable data must remain within Canada; Ontario residency is preferred
  • Minimum necessary principle: FHO+ time tracking may not require patient-level data — tools should be designed to capture category totals and activity descriptions without extracting or storing personal health information where possible
  • Audit logs and access controls: Any system handling clinical data must maintain its own audit trail and role-based access
  • Vendor agreements: Third-party tools accessing EMR data require appropriate data sharing agreements and privacy impact assessments
  • Retention and deletion: Time-tracking data should follow the same retention policies as other billing records (see Record Retention Period)

For a comprehensive overview of EMR vendors and automation capabilities, see our Ontario Clinic Automation Landscape guide.

7. Automation Opportunities for FHO+ Time Tracking

Automation Feasibility by Tracking Requirement

One of the most common questions physicians are asking is: how much of this can be automated? The answer depends on the requirement. Some elements — like rounding and cap monitoring — are straightforward to automate. Others, like categorizing indirect care activities, still require physician input.

Requirement Automation Level Data Source Simplest Approach Ideal Approach
Direct care time (Q310) Fully automatable EMR appointment schedule Pull scheduled appointments → calculate time Real-time encounter detection from EMR + smart rounding
Telephone out-of-office (Q311) Partially automatable VoIP call logs + EMR patient matching Manual timer with Q311 tag Phone system auto-match caller ID to roster → auto-log
Indirect care (Q312) Partially automatable EMR audit logs, fax timestamps, inbox activity Timer + category dropdown + description EMR action detection (chart open without appointment = indirect care) + AI categorization
Clinical admin (Q313) Manual → Partial Calendar events, EMR system actions Manual timer with Q313 tag + description Calendar event detection + QI meeting auto-categorization
15-minute rounding Fully automatable Raw time entries Auto-round all entries using 8-minute threshold Real-time rounding with visual running total
14-hour daily cap Fully automatable Running daily total Visual warning at 12, 13, 14 hours Push notification + auto-block entry beyond cap
25%/5% ratio monitoring Fully automatable 28-day rolling category totals Weekly ratio report Real-time dashboard with threshold alerts
Activity descriptions Partially automatable User input + EMR context Free-text entry per category per day AI-suggested descriptions based on EMR actions
Continuity of care (75%) Partially automatable OHIP billing data + MCEDT reports Monthly manual import of MCEDT data Automated report parsing + early warning system
Monthly report generation Fully automatable All stored entries One-click PDF/CSV export Auto-generated OHIP submission file + physician review
Audit-ready export Fully automatable All system data Searchable log with export Immutable audit log with digital signatures + evidence attachments

Where the Biggest Automation Gains Are

EMR appointment data for Direct Care (Q310) is the highest-value automation opportunity. All three major Ontario EMRs expose appointment schedule data that can directly populate Q310 time entries. This alone eliminates the most tedious part of daily tracking for most physicians.

Phone system integration is a medium-high feasibility opportunity. VoIP systems (RingCentral, 8×8, Dialpad) expose call detail record APIs, but matching caller IDs to rostered patients requires EMR roster data. This could distinguish Q310 from Q311 automatically.

AI-assisted categorization is a promising but developing area. EMR audit logs could classify actions — such as "chart open without an active appointment" likely being indirect care — but this requires deep access to EMR activity data, which varies significantly by platform.

Fax and inbox timestamps can approximate Q312 time for tasks like reviewing lab results and processing referrals, but mapping these to billing categories still requires some physician input.

The bottom line: a well-designed tool could reduce a meaningful share of the tracking burden, with the remaining input — especially activity descriptions and Q312/Q313 categorization — requiring brief daily physician engagement. The exact degree of automation will depend on EMR access, phone system integration, and workflow design. For a comprehensive analysis of the FHO+ time-tracking landscape — including what vendors are building and where the gaps remain — see our FHO+ Time-Tracking Landscape report.

For more on the landscape of administrative burden that drives the need for these tools, see our Ontario Physician Administrative Burden research.

8. Risks, Edge Cases, and the Compliance Hotspot Map

Multi-Group, Part-Time, and Locum Physician Scenarios

Physicians in multiple FHO groups: Based on current guidance, the 14-hour daily cap and 240-hour monthly cap appear to apply at the individual physician level across all groups. A physician locuming for two FHOs on the same day cannot bill more than 14 hours total. Cross-group reconciliation methodology is unresolved — physicians working across multiple groups should confirm how reconciliation will be handled and must self-track cumulative hours in the interim.

Part-time physicians: Caps are not pro-rated. They function as maximums, not targets. Part-time physicians simply bill fewer hours. The 25%/5% ratios are self-calibrating as percentages regardless of total hours. Income Stabilization physicians are not eligible for the hourly rate, per OMA guidance.

Locum physicians: May bill Q310–Q313 when providing eligible services to the FHO's enrolled patients, subject to declaration and participation requirements. Locums must use the FHO group billing number and be registered through proper channels with the FHO group. Locums starting after April 1 must sign a new Contracted Physician Declaration (which now includes attestations about patient access and after-hours coverage). Pre-existing locums do not need to resubmit.

Critical warning: If a locum does not sign the declaration, their in-basket visits to rostered patients count against the enrolling physician's continuity of care metric.

Teaching, FHT Meetings, and OHT Governance — Where the Grey Zones Are

Teaching/precepting: Clinical teaching concurrent with patient care → Q310 at $80/hr. Patient-specific teaching (reviewing a case with learners post-encounter) → Q312 at $80/hr. Teaching not connected to specific patient care (academic lectures, curriculum planning) → not billable. Whether supervising a learner's independent patient assessment (not at bedside) qualifies as direct or indirect care remains unresolved.

FHT interdisciplinary team meetings: Patient-specific case conferences (discussing particular patients) → likely Q312. Population-level clinical improvement meetings (chronic disease protocols, screening initiatives) → likely Q313. Purely administrative/governance meetings (budget, staffing) → explicitly not billable. No OMA guidance differentiates FHT meeting types, and the 5% Q313 cap makes this categorization financially material.

Reviewing staff or NP chart notes: Interpretive guidance: When a physician spends time reviewing and signing off on chart notes completed by a nurse practitioner or staff nurse for a rostered patient, this is patient-specific indirect work and would likely qualify as Q312. However, no explicit OMA guidance addresses this scenario — physicians should document the activity clearly and monitor for future clarification.

OHT governance: Likely not billable under any code. OHT governance is not patient-specific (ruling out Q312) and is organizational/system-level rather than roster/FHO-level clinical work (ruling out Q313, which explicitly excludes non-clinical administration). No explicit guidance exists — this remains a grey area.

The Double-Billing Question and Top Compliance Hotspots

The hourly rate is designed to be billed simultaneously with shadow billing — this is the intended structure, not double-billing. The real compliance risks are:

  • Non-rostered patient time bleeding into hourly claims: Physicians seeing both rostered and non-rostered patients in the same session must carefully separate time. Only rostered-patient work qualifies.
  • Hospital-based service time: In-hospital services are now 100% FFS out-of-basket. Billing hourly rate for hospital time would be improper.
  • Delegated task time: Billing for injections given by nurses or tasks performed by other staff is explicitly excluded.
  • Uninsured service time: Third-party forms, cosmetic procedures, and other uninsured services cannot be counted toward hourly totals.
  • Time logging itself: Documenting your hours is explicitly excluded from billable time.

Top 8 compliance hotspots ranked by probability and impact:

  1. Year 1 ratio violations — exceeding 25%/5% caps without system enforcement, leading to retroactive reconciliation (HIGH probability, HIGH impact)
  2. Category misclassification — Q312 vs. Q313 overlap is significant and the definitions are not exhaustive (HIGH probability, MEDIUM impact)
  3. Telephone location confusion — Q310 vs. Q311 for in-office vs. out-of-office telephone (HIGH probability, LOW impact per instance)
  4. Missing daily documentation — failing to record activity descriptions for Q312/Q313 (MEDIUM probability, HIGH impact during audit)
  5. Monthly cap claim rejection — submitting batches that exceed the monthly limit causes full batch rejection in Year 1 (MEDIUM probability, HIGH impact)
  6. Stale date expiry — 90-day window for submissions; physicians who delay billing lose revenue permanently (MEDIUM probability, MEDIUM impact)
  7. Non-rostered patient time inclusion — inadvertently counting time for walk-in or non-enrolled patients (LOW probability, HIGH impact if caught)
  8. Consistently billing near 14-hour cap — draws audit scrutiny based on enforcement precedent (LOW probability, VERY HIGH impact)

Submission Mechanics: How to Actually Submit Q310–Q313 Claims

Physicians and medical office administrators will want to know the practical submission workflow:

  • Q310–Q313 claims are submitted through the Medical Claims Electronic Data Transfer (MCEDT) system, the same portal used for standard OHIP billing
  • Claims follow the standard billing workflow through your EMR's billing module or third-party billing software — once your vendor has deployed the Q-code update
  • Each claim requires the fee code, service date, and total time (in 15-minute units) for that category on that day
  • Claims can be batched with your regular billing submissions
  • Remittance advice (RA) will show Q-code payments alongside other OHIP payments
  • In Year 1, claims are processed on the regular OHIP payment cycle; in Year 2, they shift to whole-month payment

Confirm with your EMR vendor or billing software provider that Q310–Q313 codes are properly configured before April 1. If your vendor has not deployed the update, contact them immediately.

Vacation, Sick Time, CME, and the Income Gap

Time-based billing is for actual work done. No hours = no hourly rate income. Since FHO+ eliminates the automatic access bonus and CCM fee (which continued during absences as part of capitation adjustments), physicians who take extended time off will see a direct income reduction in the hourly rate component.

Capitation payments and GMLP continue regardless. Locum coverage during absence generates hourly rate income for the locum, not the absent physician.

Tax and Financial Planning Considerations

FHO+ hourly rate income may affect tax and financial planning. While a detailed analysis is beyond the scope of this guide, physicians should discuss the following with their accountant:

  • Whether hourly rate income is treated differently from capitation for incorporation or HST purposes
  • How additional income affects RRSP room, tax brackets, and installment payment obligations
  • Whether the shift from access bonus (automatic) to hourly rate (activity-dependent) changes income predictability for financial planning
  • Group practice implications: how hourly rate income is allocated or shared within multi-physician FHOs

Coverage and Limitations

What This Guide Confirms with High Confidence (Sourced from OMA/MOHLTC)

All fee code definitions (Q310–Q313), rates, rounding rules, daily/monthly caps, Year 1/Year 2 enforcement differences, shadow billing rates (30% most in-basket, up from 19.4%; 50% select procedures), documentation requirements (daily totals + activity descriptions), stale-date rules (standard OHIP stale-date rules apply; physicians should confirm specific submission windows for new Q-codes with their billing service), continuity of care formula and penalty structure, contract/declaration deadlines, patient attachment bonus values (Q053–Q056), and the additive nature of the hourly rate are confirmed from official OMA publications, primarily the FHO+ Hourly Rate page (last updated February–March 2026). For broader OHIP billing optimization strategies beyond FHO+ codes, see our OHIP Billing Optimization Guide.

What This Guide Infers with Reasonable Confidence

Workflow billing category assignments (which activities map to Q312 vs. Q313), audit approach for FHO+ codes (based on existing OHIP audit framework), revenue impact estimates (illustrative scenarios based on CMA administrative time data + confirmed rates), documentation sufficiency thresholds (based on OMA examples and EPC precedent), record retention recommendations (based on CPSO/CMPA/HIA standards), EMR API capabilities and integration approaches (based on vendor documentation available as of early 2026), and multi-group hour allocation rules.

Unresolved Questions Requiring Further Clarification

  1. Exact definition of "visit" for continuity of care — OMA states details "will be determined through implementation"
  2. Year 1 reconciliation timeline for ratio cap overpayments — "at a later date" is the only guidance
  3. EPC Billing Brief for Q310–Q313 — none issued as of March 2026; this is a significant gap in official guidance
  4. Whether data analytics will be deployed proactively for FHO+ billing patterns (Auditor General's recommendations suggest yes)
  5. OMD's specific FHO+ time-tracking tool features — referenced but not publicly documented
  6. FHO contract's exact documentation obligations — behind OMA member paywall
  7. How audit infrastructure adapts to non-patient-level, non-start/stop documentation (novel for OHIP)
  8. OHT governance billability — no explicit guidance
  9. Multi-FHO cross-group hour reconciliation — no published methodology
  10. Whether baseline continuity of care measures will be provided — OMA says "forthcoming with implementation"
  11. Teaching time boundary — precepting a learner's independent assessment (not at bedside) is unresolved
  12. FHT meeting categorization — no OMA guidance differentiates meeting types for Q312 vs. Q313

How to Stay Updated

FHO+ implementation details are evolving. To stay current:

  • Monitor the OMA website (oma.org) for updated FHO+ guidance and member communications
  • Subscribe to OMA e-bulletins and the SGFP Chair's Letters
  • Check OntarioMD (omdeducates.com) for EMR-specific implementation updates
  • Watch for EPC Billing Briefs on Q310–Q313 at ontario.ca
  • Consult your billing agent or OMA practice advisor for practice-specific questions

Sources Relied Upon

Tier 1 — Official: OMA FHO+ Hourly Rate page (oma.org), OMA FHO+ Main page, OMA Continuity of Care page, OMA Post-Payment Review FAQ, OMA Agreements and Forms page, EPC Billing Brief on time-based services (ontario.ca), CPSO Medical Records Management policy, SGFP Chair's Letters.

Tier 2 — Authoritative third-party: DoctorCare FHO+ analysis (doctorcare.ca), Bill Medics strategic analysis (billmedics.ca), MedPros FHO+ guide (medpros.ca), OSCAR Pro FHO+ blog (oscarpro.ca), Healthy Debate continuity analysis (healthydebate.ca), Ontario Auditor General reports, BC Doctors of BC LFP documentation, RACGP Medicare compliance FAQ, PhysiciansForYou FHO+ analysis (physiciansforyou.com).

Tier 3 — Technical: OSCAR EMR API documentation (oscaremr.atlassian.net, worldemr.org), Accuro API portal (accuroemr.com), PS Suite integration documentation (cognisantmd.com, 6b.health), Azure Canada compliance documentation (learn.microsoft.com).

This research is part of OpsMed's ongoing work on operational challenges facing Ontario family physicians. Need help setting up compliant FHO+ billing workflows? See our FHO+ service. Have questions about workflow, documentation, or implementation? Contact us.