Can Your Physician Charge You Any Fees for the Removal of Neurofibromas

Further to certain questions raised by some of our members, our President requested the opinion of the Régie de l'assurance maladie du Québec [Quebec Health Insurance Board] on the question of insured services in cases of surgery for the removal of cutaneous, or surface, neurofibromas. Dr. Huguette Vigeant, a consulting physician with the Service de l'expertise médicale, dentaire et optométrique [medical, dentistry and optometry assessment services] of the Board, communicated the information concerning the remuneration of physicians under the circumstances submitted by the ANFQ.

As the information provided by the Board is formulated in professional and technical terms, Dr. Vigeant accepted that we communicate it to you in a more accessible language, avoiding uncommon terms and expressions. She agreed to revise our version, and this version was approved by the Director, Professional Affairs.


Small glossary applicable to neurofibromatosis that could be useful in comparing the languages:

  • Lesion: a fibroma
  • Benign tumour: a surface or cutaneous fibroma
  • Cutaneous neurofibromatosis lesion: a surface, superficial or cutaneous fibroma
  • Exeresis (action by which a fibroma is removed): removal, ablation or excision
  • General practitioner: a physician who does not specialize in one area
  • Medical specialist: for the removal of neurofibromas, the specialists concerned include dermatologists, general surgeons, neurosurgeons and plastic surgeons
  • Insured service: a service for which the physician is remunerated by the Board and not by the patient
  • Medical office: a physician's private office
  • Suture: stitching performed to close a wound

The Board's reply was drawn from three documents: the Health Insurance Act (and the Regulation respecting its application), the Entente des médecins omnipraticiens [general practitioners' agreement] and the Entente des médecins spécialistes [medical specialists' agreement].

HEALTH INSURANCE ACT

Pursuant to section 3, insured services are services rendered by a physician that are medically required. The removal of benign tumours, such as cutaneous or surface neurofibromas, is an insured service (payable to the physician by the Board).

Section 22 of the Regulation respecting the application of the Health Insurance Act lists the services that "... shall not be considered as insured services for the purposes of the Act", that is, for which the physician can request remuneration from the patient, in paragraph (c): "any service provided for purely esthetic purposes."

A few of our members told us that certain physicians asserted to them that the removal of cutaneous, or surface, neurofibromas that did not cause any pain or discomfort is a service provided for "purely esthetic purposes" and not covered by health insurance. However, the Board is of the opinion that a neurofibroma is a tumour and, consequently, its removal is an insured service, for which the physician is remunerated by the Board and cannot exact any payment whatsoever from the patient.

In fact, another section of the Health Insurance Act (section 22) prohibits any physician who provides an insured service from claiming remuneration from the patient for the provision of the service or for practice fees, other than those provided for by his/her agreement (see below).

GENERAL PRACTITIONERS' AGREEMENT

  • a) Removal of several or "multiple" neurofibromas: up to a maximum of 20 fibromas
  • b) Removal of "non multiple" neurofibromas, that is, one at a time: up to a maximum of 4 fibromas
  • Notes
    1. Certain fees associated with the use of surgical trays are payable by the Board: the physician cannot charge these fees to the patient.
    2. If the general practitioner proceeds with the removal of the fibromas in his/her medical office, he/she may request compensation from the patient for the cost of the medications or anesthetics used (if these costs appear exaggerated, the patient may contact the Collège des médecins du Québec [Quebec college of physicians]).

MEDICAL SPECIALISTS' AGREEMENT

(dermatologists, general surgeons, neurosurgeons, plastic surgeons or others, as applicable)

  • a) Removal of fewer than 5 neurofibromas (4 fibromas or less):
    • I) Operation with no suture: . on the face, neck or genitals: 1 fibroma per session, regardless of its size . on the other areas of the body: fibromas of 5 cm or less: 1 fibroma
    • fibromas of over 5 cm: 4 fibromas or less II) Operation with suture: . on any area of the body: 4 fibromas or less Note: All services always remain insured. The physician cannot exact or receive payment for the removal of additional fibromas, regardless of the number of fibromas removed.
  • b) Removal of 5 neurofibromas or more:
    • There is no set limit for the number of fibromas that a medical specialist can remove in each session and for which he/she is remunerated by the Board under a particular code.
    • Note : Under all circumstances, when the medical specialist performs the operation in his/her private medical office, he/she can claim the cost of the medications and anesthetics from the patient. But the patient has no other amount of money to disburse.

Version drafted by Alfred Dubuc, for the ANFQ

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