Ontario’s financial services regulator has an eye on medical services delivery related to auto accident insurance claims in the province.
“When a person is injured in a motor vehicle accident and seeks medical treatment from a licensed health service provider (HSP), it is essential that their benefit dollars are used effectively towards their care and recovery,” the Financial Services Regulatory Authority (FSRA) says in a press release on its third Health Service Provider Supervision Plan.
FSRA’s licensing of HSPs allows them to be paid directly by auto insurers for the rehabilitative and health expenses of Ontarians injured in motor vehicle accidents.
“Direct billing reduces the need for consumers to pay out of pocket and wait for reimbursement,” FSRA says. “Requirements exist for policies, procedures, and best practice standards to avoid the submission of false or misleading information to insurers to address the risk of incorrect or inconsistent billing practices or fraud.”
As part of its 2022-2024 Health Provider Supervision Plan, the regulator says it’s conducted three supervision initiatives that found “a high level of non-compliance by health service providers.” Despite efforts to raise awareness about healthcare provider obligations, it notes, the conduct has continued.
News reports going back nearly a decade show a long-term trend of some healthcare providers billing excessive hours for accident benefits recipients.
Seeking improvement
For 2024 through 2026, FSRA says it will focus on improving compliance to ensure HSPs are billing automobile insurers properly for benefits claimed under the provincial Insurance Act’s Statutory Accident Benefits Schedule.
The regulator says its third supervision plan will include:
- Verifying compliance among top-billing health service providers in the Health Claims for Auto Insurance (HCAI) system who have never been reviewed by FSRA.
- Understanding the management of preferred provider network agreements by insurers and health service providers to ensure fair treatment of customers and compliance with regulatory requirements.
- Identifying health service providers with sanctioned practitioners on their HCAI roster and conducting reviews for unauthorized activity in the HCAI system.
The current supervision plan says FSRA recently re-evaluated its review process for sanctioned practitioners to improve efficiency and regulatory effectiveness. It notes that data from the HCAI system is ‘anonymized’ and then captured in a Health Claims Database (HCDB). Any identified sanctions are then cross-referenced with the HCDB to see if a sanctioned practitioner’s credentials were used when not authorized.
FSRA adds its analysis of the HCDB confirms over the past 10 years that six health regulatory colleges accounted for more than 85% of the total HCAI billing. They are:
- College of Chiropractors of Ontario
- College of Massage Therapists of Ontario
- College of Occupational Therapists of Ontario
- College of Physicians and Surgeons of Ontario
- College of Physiotherapists of Ontario
- College of Psychologists of Ontario
“FSRA will focus on identifying and reviewing sanctioned members of these six health regulatory colleges where there is significant HCAI billing,” the regulator’s supervision plan says.
“It is prohibited for an HSP to submit false or misleading documents to an insurer regarding the licensing status of a person who provides goods or services to a claimant. HSPs engaging in unfair or deceptive acts or practices may be subject to investigation and enforcement action by FSRA.”
The regulator says its 2024-2026 supervision activities are underway and that it “expects health service providers to review the supervision plan and other relevant publications to ensure awareness and compliance with regulatory requirements.”
Feature image by iStock/sorbetto
