Confusion abounds this week over who is supposed to pay for what when it comes to blood work in Ontario after a series of tweets sparked a social media firestorm involving LifeLabs, OHIP and how they fit together.

LifeLabs, the Ministry of Health and the ruling Ontario PC Party have all stated in recent days that there have been no changes to OHIP-covered services.

And yet, patients continue to share receipts and stories online about tests for which they've been charged recently that they'd never been charged for in the past.

Contradictory as it sounds, neither group is lying. OHIP hasn't de-listed any tests. What does appear to have changed are some eligibility requirements for specific tests to be covered by OHIP.

A blood serum test ordered by your family doctor that may have been covered previously, before 2020, might now need to be ordered by a specialist in order for OHIP to pick up the tab. A cancer screening test might now only be insured for people with previous diagnoses of cancer.

Everyone can still get all the tests — they just have to meet a stricter criteria to get certain tests for free. I'll explain it all below after a preface for those unaware of what's going on.

Wow you got printed receipts. Better than my handwritten ones. #onpoli #OHIP pic.twitter.com/TcNqthQnJU

— J. Benzo Peterson (@johnnypolitic) May 31, 2022

While both LifeLabs and OHIP started trending on Twitter Monday morning, chatter had been swirling for months that the province wanted to scale back some types of coverage under its public health insurance plan.

One Ontario resident's tweet about paying $86 at LifeLabs for "cancer screening blood work" went viral over the weekend, prompting hundreds of others to speak out about how they, too, had been recently charged for blood tests that they didn't remember paying for in the past.

"Ontario...if you haven't had to have bloodwork done lately, or screening tests, you're in for quite a shock. 86$ dropped at LifeLabs today thanks to [Doug Ford] taking cancer screening blood work off the list of OHIP covered test," reads the original tweet. "Just the beginning of privatization by stealth."

With an election just a day away, critics of the Ford government amplified this message and others like it, accusing the province of covertly carving away at the list of services and medications covered by OHIP.

Ontario's Ministry of Health was quick to clarify in a statement that "there have not been any changes to tests that are covered under the OHIP schedule of benefits-labratory services that may have led to a patient being charged."

The Ontario PC Party told blogTO similarly that "there have been no changes to OHIP billing," blaming the outcry on "disinformation that has been circulated by Liberals and NDP candidates."

LifeLabs, the largest provider of community laboratory services in Canada, issued a statement saying pretty much the same thing.

"The Ontario Government prescribes which tests are covered by OHIP. There have not been any laboratory tests de-listed (i.e. removed with no replacement test) in the last five years under the Ontario Health Insurance Plan Schedule of Benefits for Laboratory Services," reads the statement.

"LifeLabs cannot bill individuals with OHIP coverage for tests that are covered by OHIP."

And yet, patients are still sharing receipts and stories online about tests for which they've been charged recently, but were not in years past.

@OntarioHealthC I found this pdf via LifeLabs it looks like the change was early 2020. These were incl in my bloodwork at no cost to me via LifeLabs last time I got work done in 2018-19. Unless in hospital, all bloodwork goes via LifeLabs in my area.🙄https://t.co/ij6FGisXO2 pic.twitter.com/mYZrJ3dbgL

— °★Cαƚ★Lαԃყ★° (@PersianCatLadyJ) May 30, 2022

True as it may be that no tests have been taken off the list of things covered by OHIP, it appears as though certain eligibility criteria changed in 2020.

"A community laboratory can only accept Laboratory Requisitions that meet the stated requirements in this Schedule. If a Laboratory Requisition does not meet the requirements, any tests performed for that order will not be eligible for payment," reads a document on the Ministry of Health's website entitled Schedule of Benefits for Laboratory Services, dated July 1, 2020.

The document specifies that this Ontario Health Insurance Plan, Laboratories and Genetics branch schedule was created under Regulation 552 of the Health Insurance Act and that it is effective as of July 1, 2020.

In Section 1.4 of the schedule, we see a number of very specific rules for different kinds of blood tests, all of which must be followed in order for the test to be covered by OHIP.

Some types of blood tests, for instance, are only insured when ordered by medical specialists — meaning that charges will apply if your test is prescribed by a general practitioner.

A serum folate test, useful for diagnosing patients with anemia, "is only insured for persons when ordered by or on the advice of a physician with expertise in hematological or gastrointestinal disorders," according to the schedule.

An aspartate aminotransferase (AST) test, which checks for liver damage, must be ordered "by or on the advice of a physician with expertise in hepatic disorders."

Prostate specific antigen tests are covered under OHIP only for "men who have been diagnosed with, or are receiving treatment for, or are being followed after treatment for prostate cancer, or whose health care practitioner suspects prostate cancer because of their history, race, and/or the results of their physical examination," while a carcinoembryonic antigen test is an insured service with established malignancies in the picture, "not as a general cancer screen."

So yes — all of these tests are still covered by OHIP, but only for people with certain diagnoses or when ordered by specialists.

I have heard this a lot lately from my patients whom I have sent for routine labs in Ontario - things that they never had to pay for before. Out of nowhere! Voters be aware and be warned!

— Dr. Carla Edwards (@Edwards10Carla) May 29, 2022

It's unclear when some of these rules changed, but images from a LifeLabs document circulating on Twitter suggest that eligibility criteria changed for some insured blood tests in early 2020, specifically those AST, Serum Folate and RBC Folate.

"Effective February 2 2020, LifeLabs will begin charging patients for the serum AS, serum folate and RBC folate tests. except in certain circumstances, where they will be insured. This is being done on a directive from the Ontario Ministry of Health and Long-Term Care," reads the document.

"For an AST test to be insured it can only be ordered by a health care provider (HCP) with experience in treating diseases of the liver, such as hepatologists and gastroenterologists.

"In addition, The HCP MUST indicate on the requisition that the requisition that the test is insured for the patient not to the test is insured for the patient not to be charged."

The aforementioned 2020 Schedule of Benefits for Laboratory Services specifies no less than three times that physicians also need to write "uninsured" beside the test name if a test is not an insured service.

"It is the authorized healthcare practitioner's responsibility to inform the patient when the service is not an insured service and that the patient is expected to pay for the service," reads the document. "The patient will be responsible for payment."