Individuals who suffer an injury as a result of a motor vehicle accident may need to make an insurance claim to cover their health and rehabilitative expenses. The Financial Services Regulatory Authority of Ontario (FSRA) licenses Service Providers, allowing them to receive direct payment from auto insurers for benefits claimed under the Statutory Accident Benefits Schedule (SABS).
A licensed Service Provider is a business that provides goods and services to SABS claimants. Licensed Service Providers submit invoices on behalf of claimants through the Health Claims for Auto Insurance (HCAI) system and are paid directly by insurers. As of October 2022, there were 4912 active Service Providers licensed in Ontario.
During fiscal year April 1, 2021 – March 31, 2022, there were over $643.5 million in adjudicated invoices processed through the HCAI system and over 54,000 new claimants who accessed treatment for SABS claims following a motor vehicle accident. Approximately 99% of all invoices processed through the HCAI system are from Service Providers who are licensed with FSRA. The billing volume and number of new claimants reported annually in the HCAI system signify the importance of effective supervision in this sector.
2021-2022 Year in review
During fiscal year 2021-2022 FSRA ran three review programs:
- Phase 1 Desk Reviews - Common findings in this phase related to unsigned OCF-21 invoices, policies and procedures not established or sufficient and HCAI rosters being outdated/inaccurate.
- Phase 2 Desk Reviews - All non-compliant findings in this phase related to Service Providers not adhering to the calculation method prescribed in the Fee Rule.
- Sanctioned Practitioner Reviews - There were 90 licensed Service Providers who had a sanctioned practitioner listed on their current HCAI roster.
The full Health Service Provider 2021-2022 Market Conduct Compliance Annual Report is available on our website and provides the detailed results of the supervisory work that was conducted.
Supervision focus areas for 2022-2024
The outcomes of FSRA’s 2021-2022 reviews and input from stakeholders, point to a need for better understanding of regulatory requirements. Based on this feedback, our supervision reviews will focus on higher risk Service Providers. FSRA is committed to increasing awareness of compliance obligations. A more compliant sector will help to ensure fair treatment for claimants who access SABS benefits following a motor vehicle accident.
FSRA’s supervision initiatives in 2022-2024 will concentrate on the following:
- Insurer-Initiated Examination (IE) Reviews - These Service Providers have care and control of confidential medical information of Ontario consumers and insurers rely on these clinics to assist with the adjudication of consumer benefits. The conduct and practices of these operations have a significant impact on consumers’ benefit limits.
- Focused Compliance Reviews - These reviews will focus on common areas of non-compliance and will primarily involve Service Providers who have never been the subject of an examination.
- Sanctioned Practitioner Reviews - Sanctioned practitioners pose a potential risk to the industry if consumers’ benefit limits are utilized to pay for services provided by practitioners who are not authorized to provide them.
FSRA expects Service Providers to review the supervision plan, and other relevant publications, to ensure they’re complying with the law and licensing requirements.
This supervision plan provides stakeholders and licensees with an overview of FSRA’s supervision plans for the Health Service Provider (HSP) sector in 2022-2024. FSRA’s supervision activities in 2022-2024 will continue to focus on fostering compliance and awareness in the HSP sector to help reduce fraud. FSRA will continue to focus on ensuring that Service Providers are billing auto insurers appropriately for benefits claimed under the SABS.
FSRA is committed to an open, transparent and collaborative approach that involves stakeholders and ensures broad input and perspectives to inform its direction. The Health Service Provider Stakeholder Advisory Committee (HSP SAC) is an important part of FSRA’s stakeholder engagement process. FSRA has revised the HSP SAC Terms of Reference to focus discussions on supervision in accordance with the scope of FSRA’s oversight. The feedback from HSP SAC members has been extremely informative, compelling FSRA to extend the supervision plan to a two-year period. This will allow FSRA to continue its collaboration efforts with HSP SAC members on current and future supervision priorities in the sector.
FSRA is responsible for licensing Service Providers in the HSP sector. As of October 2022, there were 4912 active Service Providers licensed in Ontario. A licensed Service Provider is defined as a business that provides goods and services to SABS claimants, submits invoices on behalf of the claimants through the HCAI system and is paid directly by the insurer.
A FSRA licence allows a Service Provider to receive direct payment from insurers for benefits claimed under the SABS. All Service Providers must submit requests and billing for goods and services via HCAI, but only Service Providers licensed with FSRA can receive direct payments from insurers.
Licensed Service Providers are subject to compliance requirements set out in Ontario Regulation 90/14 (Service Providers – Standards for Business Systems and Practices and other Prescribed Conditions), which prescribes standards relating to business systems and practices and operations management.
Most Ontarians who have been involved in a motor vehicle accident access the care they need to recover through Service Providers who are licensed with FSRA. The billing volume and number of new claimants reported annually in the HCAI system signify the importance of effective supervision in this sector. For example:
- During fiscal year April 1, 2021 – March 31, 2022, over $643.5 million in adjudicated invoices were processed through the HCAI system.
- Since the inception of the HCAI system in 2009, over $8.2 billion in adjudicated invoices have been processed.
- During fiscal year April 1, 2021 – March 31, 2022, there were over 54,000 new claimants who accessed treatment for SABS claims through the HCAI system following a motor vehicle accident.
Health Service Provider Stakeholder Advisory Committee
The HSP SAC provides insights and advice on HSP supervision in accordance with the scope of FSRA’s oversight mandate. To achieve our supervision objectives, FSRA continues to engage with HSP SAC members to assist in the development of our supervision priorities and key areas of risk assessment.
The Terms of Reference for the HSP SAC are directly related to FSRA’s role in supervising the HSP sector, which include:
- licensing service providers that bill auto insurers directly for medical and rehabilitation services provided to automobile insurance accident benefits claimants,
- regulating the business and billing practices of licensed service providers, and
- collecting information about licensed service providers’ business systems and practices through an Annual Information Return (AIR).
Extending the supervision plan to a two-year period will allow FSRA to conduct active supervision programs while continuing to engage with HSP SAC members on an ongoing basis. Over the next two years, FSRA is committed to continuous engagement and collaboration with the HSP SAC. The input and feedback from members will help guide our examinations and ensure that any new compliance related developments in the sector are captured.
Supervision focus areas for 2022-2024
To address key issues in the HSP sector, FSRA’s supervision initiatives in 2022-2024 will concentrate on the following:
- Insurer-Initiated Examination (IE) Reviews
- Focused Compliance Reviews
- Sanctioned Practitioner Reviews
1) FSRA has started conducting IE Reviews
Service Providers who indicated in their 2021 AIR that they provide IEs were selected for a desk review. For the purposes of assisting an insurer to determine if an insured person is, or continues to be, entitled to a benefit an insurer may require an insured person to be examined under s. 44 of O. Reg. 34/10. IEs are examinations required by an insurer. An insured person may be examined by one or more persons chosen by the insurer who are Regulated Health Professionals (RHPs) or who have expertise in vocational rehabilitation.
Service Providers who conduct IEs provide medical recommendations that insurers rely on to determine consumers' benefit entitlements. These Service Providers have care and control of confidential medical information of consumers and insurers rely on these clinics to assist with the adjudication of consumer benefits. Given the impact on consumers, FSRA is conducting a review focused on these Service Providers to ensure they are compliant with their regulatory requirements.
2) FSRA will conduct Focused Compliance Reviews in 2022-2024
FSRA has received feedback from numerous stakeholders recommending that supervision efforts should be focused on educating the sector. In our Health Service Provider 2021-2022 Market Conduct Compliance Annual Report we have included a section titled “Education for the Sector on Common Supervisory Findings”. The goal of this section is to increase compliance and awareness in the HSP sector by reminding sector participants of their compliance requirements.
The most common areas of non-compliance identified by FSRA in its 2021-2022 reviews are as follows:
- OCF-21 invoices not signed,
- Policies and procedures not established or sufficient,
- HCAI roster outdated/inaccurate, and
- Incorrect calculation of SABS claimants.
FSRA will conduct Focused Compliance Reviews targeting the common areas of non-compliance that we have identified since the HSP sector came under regulation in Ontario, including those noted above. These reviews will primarily focus on Service Providers who have never been the subject of an examination. We will continue to engage with the HSP SAC, and other stakeholders, to obtain input and feedback on risk assessment criteria and the use of data (i.e., HCDB, AIR, complaints). This will help FSRA prioritize which Service Providers should be subject to an examination and will help inform and improve the effectiveness of our reviews.
3) FSRA is continuing to conduct Sanctioned Practitioner Reviews
A sanctioned practitioner is a RHP who has been sanctioned by their health regulatory college. Licensed Service Providers who are identified as being affiliated with sanctioned practitioners will be examined for suitability in the HSP regime and investigated for unauthorized activity in HCAI (e.g., inappropriate billings or invalid authorizations).
The Regulated Health Professions Act, 1991 (RHPA) and health profession Acts (i.e., Medicine Act, 1991) establishes the legislative framework for health regulatory colleges, which regulate the professions in the public interest. Health regulatory colleges are responsible for ensuring that RHPs provide health services in a safe, professional and ethical manner. This includes setting and overseeing standards of practice and quality of care for the profession, investigating complaints about members of the profession and, where appropriate, disciplining them. FSRA’s oversight pertains to the business and billing practices of licensed Service Providers related to auto insurance claims under the SABS.
FSRA’s Market Conduct team reviews health regulatory college websites to gather information and uses this data to inform its risk selection criteria for supervisory reviews. FSRA is looking to strengthen our relationships with health regulatory colleges. We are exploring opportunities to work with health regulatory colleges to build stronger partnerships in the oversight of the HSP sector.
FSRA helps to protect the rights of consumers by promoting high standards of business conduct and transparency within the HSP sector. During 2022-2024 we will continue to focus on ensuring that licensees are compliant with their regulatory requirements related to SABS claims.
Licensed Service Providers are expected to understand and comply with the standards of practice prescribed in O. Reg. 90/14 under the Insurance Act. FSRA will continue to work with stakeholders to explore educational opportunities for the HSP sector to assist licensees in ensuring they are compliant with all regulatory requirements.
FSRA will continue to collaborate with the HSP SAC and other stakeholders, to monitor developments in the sector. We are confident that this partnership will promote transparency and foster a collaborative relationship between the regulator and sector participants.
Your feedback is welcome
FSRA welcomes comments from stakeholders on this supervision plan. Your comments will help inform our current and future supervision priorities and will increase our understanding of the HSP sector. As in previous years, we will share the findings from our supervisory reviews with the industry and consumers. You will find our Health Service Provider 2021-2022 Market Conduct Compliance Annual Report on our website.
To support our commitment to ongoing education, FSRA will be hosting a live webinar to help new and existing licensees understand their duties, responsibilities and regulatory requirements. The webinar will help participants gain a better understanding of FSRA’s compliance expectations. Participants will have the opportunity to ask questions directly to our FSRA team.
Stay tuned for more information in the coming months!