Executive summary

The Financial Services Regulatory Authority of Ontario (FSRA) is an independent regulatory agency that places a strong emphasis on consumer protection in Ontario. This includes promoting high standards of business conduct and protecting consumers’ rights and interests. 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. FSRA licenses Health Service Providers (HSPs), allowing HSPs to receive direct payment from automobile insurers for benefits claimed under the Statutory Accident Benefits Schedule (SABS).

Licensed HSPs submit invoices on behalf of claimants through the Health Claims for Auto Insurance (HCAI) system and are paid directly by insurers. As of April 1, 2024, there were 4,994 HSPs licensed in Ontario.

During fiscal years 2022/23 and 2023/24 (April 1, 2022 - March 31, 2024), HCAI processed over $1.39 billion in invoices for adjudicated claims. Approximately 99% of all invoices processed through HCAI were from HSPs licensed with FSRA, and more than 314,000 claimants accessed treatment following a motor vehicle accident. If a consumer is injured in a motor vehicle accident and seeks treatment from an HSP, it is essential that the consumer’s benefit dollars are appropriately used towards their care and recovery. Effective supervision of this sector is crucial to ensure fair outcomes for consumers.

2022-2024 in review

As part of its 2022-2024 Health Service Provider Supervision Plan, FSRA conducted three supervision initiatives which identified unacceptable levels of non-compliance by HSPs. The outcomes of these reviews, which are published in FSRA’s 2022-2024 Health Service Provider Market Conduct Compliance Report, and input from stakeholders, point to a need for better understanding of regulatory requirements in the sector. To address this, FSRA developed and delivered educational tools to support HSP sector compliance, including the Health Service Provider Quick Guide to Compliance, published in November 2022. In addition, on March 1, 2023, FSRA hosted a Health Service Provider Webinar on compliance requirements.

Supervision focus areas for 2024-2026

FSRA is committed to increasing awareness of compliance obligations and is implementing initiatives that will lead to a more informed and compliant sector. 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 during fiscal years 2024/2025 and 2025/2026 (April 1, 2024 - March 31, 2026) will concentrate on the following:

  1. HSPs that participate in Preferred Provider Networks (PPNs) – PPNs may be used to connect claimants with care following a motor vehicle accident. The insurer establishes their PPN and may refer claimants to HSPs within their network for care. The purpose of this initiative is to understand how insurers and HSPs are managing their PPN agreements to ensure fair treatment of claimants and compliance with regulatory requirements, such as the Unfair or Deceptive Acts or Practices (UDAP) Rule.

  2. Focused compliance reviews – These reviews will focus on common areas of non-compliance and will primarily involve HSPs who are top billers in the HCAI system and have never been reviewed by FSRA. The purpose of this initiative is to verify compliance and, where necessary, raise awareness of regulatory obligations with HSPs.

  3. Sanctioned practitioner reviews – These reviews will focus on identifying HSPs who have a sanctioned practitioner on their HCAI roster and conducting reviews for unauthorized activity in HCAI. The purpose of this initiative is to ensure that consumers’ benefit limits are being utilized appropriately by practitioners who are authorized to provide them.

FSRA expects HSPs to review the supervision plan and other relevant publications to ensure awareness and compliance with regulatory requirements.

Introduction

This supervision plan provides stakeholders and licensees with an overview of FSRA’s supervision plans for the HSP sector in 2024-2026. FSRA’s supervision activities in 2024-2026 will focus on fostering compliance and awareness in the sector. FSRA will continue to focus on ensuring that HSPs are billing automobile insurers appropriately for benefits claimed under the SABS.

Background

FSRA licenses HSPs, allowing them to receive direct payment from automobile insurers for benefits claimed under the SABS. The HCAI system is a mandatory platform for HSPs to submit Treatment and Assessment Plans (OCF-18), Treatment Confirmation Forms (OCF-23), and their associated invoices (OCF-21), as well as Assessment of Attendant Care Needs Forms (Form 1) to auto insurers for review and adjudication. HSPs who are not licensed with FSRA are still required to submit approved forms via HCAI, however they do not qualify for direct reimbursement. Claimants who receive care from a FSRA licensed HSP benefit from the convenience of direct billing.

In Ontario, health regulatory colleges are responsible for ensuring that Regulated Healthcare Professionals (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 HSPs related to auto insurance claims under the SABS. HSPs are subject to compliance requirements set out in Ontario Regulation 90/14 which prescribes standards relating to business systems and practices and operations management. In addition, HSPs are required to comply with the UDAP Rule which took effect on April 1, 2022. The UDAP Rule strengthens the supervision of the industry and enhances consumer protection by clearly defining outcomes that are deceptive or unfair and hence harmful to consumers. HSPs engaging in unfair or deceptive acts or practices may be subject to investigation and enforcement action by FSRA.

The following are FSRA’s objects in the HSP sector:

  • to regulate and generally supervise the sector
  • to monitor and evaluate developments and trends in the sector
  • to deter deceptive or fraudulent conduct, practices and activities by the sector

Supervision focus areas for 2024-2026

To address key issues in the HSP sector, FSRA’s supervision initiatives in 2024-2026 will concentrate on the following:

  1. Examinations of HSPs that participate in PPNs

  2. Focused compliance reviews

  3. Sanctioned practitioner reviews

FSRA is conducting PPN examinations

PPN arrangements are common in the insurance industry. PPNs may be used to connect claimants to care following a motor vehicle accident. The insurer establishes their PPN and may refer claimants to HSPs within their network for care. PPNs can help expediate access to HSPs who have been vetted by the insurer. It is the claimant’s choice to use the insurer’s PPN. A claimant can decline the insurer’s referral and doing so will not prejudice or adversely affect their entitlement to benefits under the SABS.

There have been concerns raised about the impact of PPNs on insurance consumers. Those who have raised concerns say that PPNs restrict a claimant’s ability to choose where they receive medical treatment or health services. Additionally, concerns have been raised alleging that HSPs solicit referral fees in connection with goods and services provided to claimants. The UDAP Rule prohibits a referral fee from being solicited, demanded, paid, or accepted in connection with goods or services provided to a claimant. As a result of these concerns, FSRA initiated an information gathering exercise to better understand the operational practices of PPNs, including compliance with legislative requirements and best practices. The information gathered verified the potential for risks within PPN arrangements.

FSRA has started conducting examinations of HSPs that participate in PPNs to address concerns related to these arrangements. It is imperative that licensees who participate in PPN arrangements comply with all applicable requirements of the Insurance Act, its regulations, guidance and FSRA Rules, including the UDAP Rule.

FSRA will conduct additional focused compliance reviews

A concerning outcome of the focused compliance reviews conducted during 2022-2024 was the low compliance rate of only 29%. The remaining 71% of HSPs reviewed were issued a warning letter for failing to comply with regulatory requirements. The most common areas of non-compliance identified by FSRA in 2022-2024 were:

  • inaccurate HCAI rosters
  • failure to report business changes to FSRA
  • inadequate policies and procedures
  • inaccurate reporting of SABS claimants

To expand FSRA’s reach across the sector and increase awareness of compliance obligations, FSRA will conduct additional focused compliance reviews during 2024-2026. These reviews will involve HSPs who have never been reviewed by FSRA and are top billers in the HCAI system.

FSRA is continuing to conduct Sanctioned practitioner reviews

FSRA monitors health regulatory college websites to identify sanctions placed against RHPs. These sanctions may result in a restriction, suspension or revocation of a certificate of registration imposed by the health regulatory college. If a certificate of registration is suspended or revoked, it is prohibited for a practitioner to use their credentials to certify, provide or bill for specific listed expenses in HCAI. FSRA will continue to notify HSPs who have a sanctioned practitioner on their HCAI roster and conduct reviews for unauthorized activity in HCAI.

In Ontario, health regulatory colleges are responsible for ensuring that RHPs provide health services in a safe, professional and ethical manner. This includes setting standards of practice for the profession, investigating complaints about members and disciplining them, where appropriate.

FSRA’s oversight in this multifaced sector pertains to the business and billing practices of HSPs. Data transmitted through the HCAI system is anonymized and captured in the Health Claims Database (HCDB). Identified sanctions are cross referenced with the HCDB to determine whether a sanctioned practitioner’s credentials were used when not authorized.

FSRA has re-evaluated the sanctioned practitioner review process to enhance efficiency and regulatory effectiveness. FSRA has utilized the HCDB to confirm that over the past 10 years, the six health regulatory colleges below have accounted for over 85% of the total HCAI billing:

  • 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. 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.

HSP supervisory tool

In the 2024 Ontario Budget, the Ontario Government included a request that FSRA conduct a review of the HSP Framework. To support FSRA’s statutory objects, its 2024-2027 Annual Business Plan and the Ontario Government’s budget commitment, FSRA is reviewing the HSP Framework and setting out administrative and cost-efficient options to modernize the system and make it more efficient.

FSRA has identified various initiatives that can provide administrative and cost efficiencies to contribute to having a more modern and efficient HSP Framework. One of the identified options includes creating a new HSP supervisory tool. From September 27, 2024 – November 29, 2024, FSRA solicited stakeholder feedback on the proposed initiatives through a public Auto Reform Consultation. Stakeholder input will be used to inform FSRA’s recommendations and to advance the Government’s commitments to improve Ontario’s auto insurance system.

The development of a new HSP supervisory tool would allow FSRA to modernize its supervisory approach. Specifically, a new tool would gather multiple data sources and provide analytics in support of risk-based supervision, improving compliance decision-making and identifying sector trends. The tool would allow FSRA to be more proactive and to focus its resources on areas with the highest risk.

The timeframe for this tool is under assessment with no specific transition or launch date.

Conclusion

FSRA helps to protect the rights of consumers by promoting high standards of business conduct and transparency within the HSP sector. During 2024/25 and 2025/26, FSRA will continue to focus on fostering compliance and awareness in the sector to help reduce opportunities for fraud and ensure financial safety and fairness for Ontarians. Licensed HSPs must comply with all applicable requirements of the Insurance Act, its regulations and FSRA Rules.

FSRA is exploring opportunities to strengthen the risk assessment of HSPs and will continue to collaborate with sector participants to assist in the development of our supervision priorities and key areas of risk assessment. FSRA will also consider whether further action, including escalation to enforcement, is necessary to ensure sector compliance with regulatory requirements. A more compliant sector will help to ensure fair treatment for claimants who access SABS benefits following a motor vehicle accident.

Your feedback is welcome

FSRA welcomes comments 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.