This supervisory plan provides stakeholders and licensees with an overview of the Financial Services Regulatory Authority of Ontario’s (FSRA) supervision plans for the Health Services Provider (HSP) sector in 2021-2022. As in previous years, the objective of FSRA’s supervisory activities in the HSP sector will be to foster compliance and awareness in the sector to help reduce fraud so that auto insurance rates don’t increase unnecessarily.
FSRA helps to protect the rights of consumers by promoting high standards of business conduct and transparency within the sectors that it regulates. Consistent with this purpose, FSRA is responsible for licensing Service Providers in the HSP sector. As of June 30, 2021, there are over 5,000 active Service Providers licensed in Ontario. A licensed Service Provider is defined as a business that provides goods and services to Statutory Accident Benefits Schedule (SABS) claimants, submits invoices on behalf of the claimants through the Health Claims for Auto Insurance (HCAI) system and is paid directly by the insurer. Regulatory Colleges oversee the standards of practice and quality of care provided by Regulated Healthcare Professionals (RHPs).
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. For example:
- During fiscal year April 1, 2020 – March 31, 2021 over $600 million in adjudicated invoices was processed through the HCAI system.
- Since the inception of the HCAI system in 2009, over $7 billion in adjudicated invoices have been processed.
- During fiscal year April 1, 2020 – March 31, 2021 there were over 46,000 new claimants who accessed treatment for SABS claims through the HCAI system following a motor vehicle accident.
The billing volume and number of new claimants reported annually in the HCAI system signify the importance of effective supervision in this sector.
A FSRA licence allows a Service Provider to receive direct payment from insurers for benefits claimed under the SABS. 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. In reviewing evidence of non-compliance under these regulations, FSRA’s HSP regime helps to reduce fraud so that auto insurance rates don’t increase unnecessarily.
Supervision focus areas for 2021-2022
FSRA’s 2020-2021 HSP reviews focused on licensed Service Providers who had non-compliant findings from past desk reviews or on-site examinations. FSRA found that 88% of licensed Service Providers resolved deficiencies identified in previous reviews. Additionally, FSRA reviewed a total of 242 sanctions issued by Regulatory Colleges and found two licensed Service Providers that billed using the credentials of a sanctioned RHP. The two cases were escalated to Licensing and Enforcement. Finally, as part of FSRA’s response to COVID-19, reviews were expanded to include a virtual care questionnaire to ensure compliance with FSRA’s “Statutory Accident Benefits Claims during the COVID-19 Outbreak” Guidance. FSRA did not identify any instances where reasonable accommodations were not provided.
This work assisted in fostering compliance and awareness in the HSP sector. FSRA’s supervision activities in 2021-2022 will continue this work with emphasis placed on overseeing the billing practices and business systems and practices of licensed Service Providers engaged in providing goods and services to SABS claimants. The 2021-2022 supervision activities will also focus on utilizing data available through the Health Claims Database (HCDB).
In December 2020, FSRA obtained access to data available through the HCDB. Data transmitted through the HCAI processing system is scrubbed of any identifying personal information or personal health information of claimants and is captured in the HCDB. FSRA plans to leverage this new data to validate information reported in the Annual Information Return (AIR) that all licensed Service Providers are required to file with FSRA, and to validate that licensed Service Providers are not billing using the credentials of RHPs who have had sanctions placed against them by their Regulatory Colleges.
Through the course of its review activities, FSRA may find evidence of non-compliance by Service Providers. In these cases, FSRA’s response may include education, warnings or cautions, undertakings (Minutes of Settlement), or Administrative Monetary Penalties, depending on the severity of the non-compliance. Additionally, Service Providers may be required to surrender their licenses, or FSRA may suspend, revoke or place conditions on licenses.
Annual Information Return results
All licensed Service Providers are required to file an Annual Information Return (AIR) and pay an annual regulatory fee (ARF). FSRA recognizes that COVID-19 has impacted Service Provider’s business activities. To allow some flexibility for Service Providers, the 2020 AIR was delayed – it launched on April 9, 2021 and was due on June 30, 2021. As of July 31, 2021, 79.5% of licenced Service Providers have filed the AIR and paid the ARF. Service Providers that filed the AIR late will be issued Caution Letters. Non-filers of AIR could have their licence suspended or revoked. This year, FSRA revoked the licences of 174 service providers that did not file their AIR and pay the mandatory regulatory fee more than once.
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 2020-2021 Market Conduct Compliance Annual Report on our website.