Six Months Into FHO+: What Ontario Family Physicians Are Actually Seeing in Practice

When FHO+ launched on April 1, 2026, most of the discussion focused on what was changing: hourly payments, higher shadow billing, higher after-hours premiums, the end of negation, patient attachment incentives and a new Continuity of Care requirement.

Six months later, we are starting to move past the theory.

The bigger question now is: what does FHO+ actually look like in day-to-day practice?

Based on the Ministry’s implementation rules, updated OMA guidance, billing-industry reporting and the questions physicians are now asking, a few themes are becoming much clearer.

Our view at MedPros is that FHO+ remains a significant improvement to the FHO model for many family physicians, but it is also a much more operationally driven model.

Simply being in an FHO is no longer enough.

Billing accuracy, time tracking, roster management, patient access, Continuity of Care and group-level management all matter more than they did before.

1. The new hourly payment is meaningful, but only if the time is actually captured

Perhaps the biggest practical change under FHO+ is that physicians can now be paid for eligible time that previously went largely uncompensated.

The Ministry introduced four hourly codes:

• Q310A: direct patient care, generally $80/hour base rate
• Q311A: telephone care provided while outside the office, generally $68/hour base rate
• Q312A: indirect patient care, generally $80/hour base rate
• Q313A: clinical administration, generally $80/hour base rate

The Ministry has also confirmed that the applicable 2026–27 relativity adjustments apply to these payments.

Indirect care is important because it includes work family physicians have always done: reviewing results, charting, preparing referrals, reviewing consultation reports, coordinating care and certain patient-specific communications.

But the introduction of hourly billing has created a new challenge: physicians now need a reliable way to capture their time.

The OMA requires physicians to maintain daily records of the total time spent in each hourly category. Patient-by-patient start and stop times are not required, but indirect and clinical-administration records need an appropriate summary of the activities performed.

DoctorCare recently reported three recurring issues among practices it works with: eligible hours not always being billed, indirect-care time being underreported and monthly billing limits not consistently being tracked.

That may turn out to be one of the biggest lessons from the first six months of FHO+:

Revenue leakage under the new model can happen one missed 15-minute block at a time.

2. Understanding the hourly limits is just as important as submitting the codes

FHO+ is not an unlimited hourly payment system.

Current rules include:

• A maximum of 14 billed hours per day
• A monthly limit based on 240 hours per 28 days, prorated by the number of days in the month
• No more than 25% of total monthly billed hours from indirect care plus clinical administration
• Clinical administration is further limited under the Ministry formula to 5% of direct and indirect patient-care hours

For a 31-day month, for example, the maximum combined hourly billing increases to approximately 265.7 hours.

There is another important Year 1 detail physicians should understand.

The OMA advises that the daily and monthly maximums are programmed into the Ministry system now, but the 25% and 5% percentage limits are not expected to be system-enforced until Year 2. During the first year, a physician could therefore be paid on hours that ultimately exceed the permitted ratios and later face reconciliation.

In other words:

“The claim paid” does not necessarily mean “the billing was within every FHO+ limit.”

Practices should be monitoring the ratios themselves rather than waiting for the Ministry to do it for them.

3. FHO+ compensates clinical administration, not every form of administration

This is another area where there has been some misunderstanding.

Q313A does not mean every hour spent running a medical practice is now billable.

Eligible clinical-administration activities can include population-level preventive care planning, chronic-disease initiatives, certain EMR management requiring physician expertise and quality-improvement work.

It does not include general business administration such as managing employees, accounting, finances, ordering supplies, leasing, insurance or general clinic infrastructure.

The distinction matters.

FHO+ recognizes more of the clinical work that happens outside the exam room, but it has not converted physicians into hourly-paid clinic administrators.

4. Continuity of Care matters, but the penalty is more nuanced than many physicians think

The new 75% Continuity of Care (CoC) threshold has probably generated more concern than any other part of FHO+.

But the actual rule is important to understand.

Continuity is calculated at the individual physician level, across the physician’s roster, based on eligible in-basket visits.

At least 75% of those visits should occur with the physician, another physician in the FHO or another provider recognized as acceptable under the model.

However, falling below 75% for one quarter does not automatically result in a 15% capitation reduction.

The financial adjustment applies when two related measurement quarters, which are three quarters apart, are both below the 75% threshold.

If that occurs, the adjustment is calculated as 15% of the base capitation paid during the first of those two measurement quarters. It does not apply to acuity payments, and the adjustment occurs later after the Ministry has sufficient claims data to finalize the calculation.

This makes Continuity of Care less of an immediate “clawback” and more of a performance metric that needs to be watched over time.

The bigger mistake would be discovering a continuity problem months after it started.

5. Outside use no longer creates the old dollar-for-dollar negation, but it still matters

This is one of the most important changes under FHO+.

Effective April 1, 2026, the old Access Bonus and outside-use deductions ended.

The Ministry continues to provide the Outside Use Report, but the old direct deduction against the Access Bonus is gone.

That does not mean physicians should ignore outside use.

Where rostered patients repeatedly obtain applicable primary-care services elsewhere, those visits can contribute to poorer Continuity of Care performance.

This creates a very different management question.

Previously, clinics often looked at outside use primarily because it produced a direct financial deduction.

Today, the better questions are:

• Why are patients going somewhere else?
• Can they get same-day or timely access within the FHO?
• Are office hours meeting patient needs?
• Is the group using its physicians and locums effectively?
• Are patients aware of the access available through their own clinic?

That makes the Outside Use Report less about chasing individual clawbacks and more useful as an access and continuity management tool.

6. After-hours care and selected procedures have become considerably more valuable

The financial upside in FHO+ is not limited to hourly payments.

The FHO after-hours premium increased from 30% to 50% for eligible services billed with Q012.

The general blended fee-for-service payment for in-basket services increased from 19.41% to 30%, while selected in-basket procedures receive a 50% blended fee-for-service payment effective retroactively to April 1, 2026.

Importantly, hourly payments generally operate in addition to the applicable shadow billing, fee-for-service payments and premiums rather than replacing them.

For well-run FHO groups, that makes scheduling, after-hours coverage and correct procedure coding increasingly important.

It also means physicians should not judge their performance simply by looking at capitation.

The FHO+ revenue picture now includes several moving pieces.

7. Patient attachment remains a major opportunity, but there is an important October 2026 caveat

One of the objectives behind Ontario’s primary-care reforms is to encourage physicians to attach more previously unattached patients.

The new Patient Attachment Bonus was made effective retroactively to July 1, 2025.

According to current OMA guidance, the proposed amounts are:

Established physicians

• $100–$150 for patients aged 0–64, depending on the practice’s RIO score
• $120–$180 for patients aged 65+

Eligible new graduates

• $150–$225 for patients aged 0–64
• $180–$270 for patients aged 65+

However, there is an important current implementation issue:

As of the latest OMA guidance, the new general Patient Attachment Bonus codes have still not been released for billing.

The OMA states that eligible claims will be capable of being submitted retroactively once implementation is completed.

That means clinics should not simply wait.

For patients being enrolled now, the appropriate enrolment process, Q200 submission where applicable, and required New Patient Declaration documentation should be completed and retained so eligible patients can be identified when the codes become available.

The bonus is also intended for genuinely unattached patients. A physician simply taking over another physician’s roster through a batch transfer does not qualify for the general attachment bonus.

This is another example of why roster management under FHO+ has become much more than an administrative task.

8. Billing reconciliation has become more important, not less

One of the earliest implementation problems under FHO+ involved the new hourly codes themselves.

The Ministry found physicians submitting hourly-rate claims at a billed amount of $0. Beginning May 1, 2026, those claims started rejecting with explanatory code V41, Incorrect Fee Billed. The Ministry specifically advised physicians to verify their remittance advices and ensure the hourly codes were configured correctly in their EMRs.

That episode is useful because it demonstrates a larger point:

A good FHO+ billing system cannot stop at claim submission.

Practices should be regularly reconciling:

• what was performed;
• what was recorded;
• what was submitted;
• what was accepted or rejected;
• what appeared on the RA; and
• whether the correct premiums and automatic payments were ultimately received.

DoctorCare is now similarly emphasizing hourly billing, Continuity of Care, errors and rejections, and roster management as core monthly FHO+ performance metrics.

9. FHO group management is becoming a much bigger job

FHO+ also increases the financial recognition of group leadership.

The Enhanced Group Management Leadership Payment adds $4 per rostered patient, up to $100,000 annually, on top of the existing GMLP.

According to the OMA, combined GMLP and Enhanced GMLP funding can reach $5 per rostered patient, up to $125,000 per year, with a minimum combined payment of $25,000 per FHO.

The additional funding comes with greater expectations around group leadership, contractual compliance and appropriate after-hours coverage.

This is important because modern FHOs increasingly require actual infrastructure behind them:

billing oversight, scheduling, locum management, roster reconciliation, performance reporting, Ministry communications, after-hours coordination and physician governance.

A FHO may be a physician organization, but operationally it increasingly needs to function like an organized medical group.

10. The biggest misconception: FHO+ does not produce the same financial result for every physician

There is understandable excitement around some of the FHO+ income examples being discussed publicly.

There is also skepticism.

Recent physician discussions online include questions about whether projected earnings are realistic, how indirect hours should be tracked, how physicians should stay within the applicable ratios and whether FHO+ makes sense compared with alternative practice models. Some physicians are using EMR workflows or separate spreadsheets simply to keep track of their hourly categories.

These conversations are useful for identifying concerns, but they should not be treated as policy guidance or income benchmarks.

There is no responsible single number for “what a FHO+ doctor makes.”

Actual results depend on factors such as:

• roster size and demographics;
• number of days and hours worked;
• direct versus indirect care;
• procedures performed;
• after-hours participation;
• patient continuity;
• practice overhead;
• hospital or other clinical work;
• roster growth;
• billing accuracy; and
• how efficiently the practice operates.

Six months is also too early to declare definitive winners and losers across the province.

What we can say is that FHO+ provides more ways to be compensated for the work involved in comprehensive family medicine, while also making accurate practice management considerably more important.

What we would be monitoring every month

If we were evaluating the health of an FHO+ practice today, we would not look at the RA alone.

At minimum, we would monitor:

1. Direct, indirect and clinical-administration hours, including the 25% and 5% limits
2. Hourly claims submitted versus payments received
3. Rejected claims and recurring explanatory codes
4. Continuity of Care percentage and trend
5. Outside use and the reasons patients are seeking care elsewhere
6. Roster changes, Q200 submissions and Ministry roster reconciliation
7. Eligible new-patient attachments and supporting declaration forms
8. After-hours and enhanced blended fee-for-service payments
9. Locum activity and payment reconciliation where applicable
10. Patient access, appointment availability and group after-hours coverage

The clinics that make these items part of a routine monthly review will have a much clearer picture of how FHO+ is actually performing.

Our view six months in

FHO+ appears to be moving Ontario family medicine in the right direction.

For the first time, the model meaningfully recognizes a larger portion of the work physicians perform outside the exam room. It improves compensation for after-hours care, increases payment for certain services and removes the old dollar-for-dollar outside-use negation structure.

But FHO+ is not passive income.

It rewards practices that are organized.

The physician still needs to provide the care. The clinic needs to capture the work correctly. The roster needs to be maintained. Continuity needs to be monitored. Claims need to be reconciled. Patients need reasonable access. And the FHO itself needs effective leadership.

That may ultimately be the biggest lesson from the first six months:

FHO+ is not simply a better billing model. It is increasingly a practice-management model.

And for physicians and groups that build the right systems around it, that may be where the greatest opportunity lies.

How MedPros Can Help

MedPros works with family physicians and FHO groups across Ontario on medical billing, FHO and group management, physician recruitment, roster and RA reconciliation, practice operations and clinic development.

Whether you are already practising within a FHO+, considering joining an existing group or looking at establishing or growing a medical clinic, our team can help you understand the operational and financial considerations behind the model.

Disclaimer: This article is provided for general informational purposes only and is not legal, financial, accounting or billing advice. FHO+, OHIP and Ministry policies may change or receive additional implementation guidance. Physicians and FHO groups should confirm current requirements with the Ontario Ministry of Health, the Ontario Medical Association and their professional advisors. Information in this article is current as of October 2026.