On March 1, 2023, FSRA hosted a webinar about compliance requirements for licenced health service providers.
The webinar helped new and existing licensed service providers understand their duties, responsibilities and regulatory requirements. Providers also gained a better understanding of FSRA’s compliance requirements.
Key areas covered included:
- Service provider obligations under the Insurance Act, its regulations and applicable FSRA Rules (an overview); and
- Key legal requirements related to the most common areas of non-compliance.
Over 300 attendees participated in the webinar and had the opportunity to ask questions directly to the FSRA team.
Health Service Provider Webinar on Compliance Requirements
Date: March 1, 2023
Presenters: Stevie Madder and Beata Morris
01:07 Good morning. My name is Beata Morris, and I'm a senior manager in our market conduct department, responsible for oversight of P&C insurance companies. Also here with me today is Stevie Madder, who's our Senior Manager for Health Service Providers. Stevie will take you through the service provider compliance requirements in our session today. Before we begin, it is important to acknowledge the land we are on is the traditional territory of many nations, including the Mississauga of the Credit, the Anishinaabeg, the Chippewa, the Haudenosaunee, and the Wendat peoples and is now home to many diverse First Nations, Inuit, and Métis peoples. To acknowledge that Toronto is covered by Treaty 13 with the Mississaugas of the Credit and the Williams Treaties signed with multiple Mississaugas and Chippewa bands.
01:55 I'm just going to cover a couple of housekeeping items for today's webinar. We are on the MST lives event, and as attendee, your audio and video have been automatically disabled. Quick reminder that today's session is being recorded. If you have any questions throughout the day, you can enter them at any time during the presentation using the Q&A icon in the top right-hand corner of your screen. We'll address the questions at the end of our presentation. And just a note, if we can not respond to all the questions today, a response will be provided along with the webinar when it is posted. You will receive notification when the materials are available for viewing on our website. Also, if questions are similar, we'll group them together so we can get to as many questions as possible today. We hope that you find today's presentation informative. And with that, let's begin. Next slide, please.
02:50 So here's our agenda for today. We're going to do an overview of health service sector and provide some recent updates in that sector. We'll provide you with an outline on the scope of the webinar. Then Stevie will cover the regulatory requirements, including reporting, business practices, and compliance. We'll also provide you with some resources available for you to access for further information. And then finally, towards the end, we'll take your questions. Next slide, please. Quick overview. So before I turn it over to Stevie, I'm going to share a brief update and highlight FSRA's role in fostering compliance and awareness in the sector. FSRA licenses service providers, allowing them to receive direct payment from auto-insurers for benefits claimed under the statutory accident benefits schedule. All service providers must submit requests and billing for goods and services via HCAI, but only service providers licensed with FSRA can receive direct payment from auto insurers.
03:49 As of February 2023, we have just under 5,000 active service providers licensed in Ontario. Approximately 99% of all invoices processed through HCAI 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. The outcomes of FSRA's compliance review 2021 for 2022 and input from all stakeholders point to a need for a better understanding of regulatory requirements. The goal of today's webinar is to increase awareness for service provider compliance obligations. And more compliance sector will help ensure fair treatment of claimants who access statutory accident benefits following a motor vehicle accident. And a final note before I hand it over to Stevie. Considering that we have a limited amount of time today and to ensure that the webinar remains focused on raising awareness of compliance obligations, we will only be answering questions related to the content presented in the webinar today. And with that, I'm going to turn it over to Stevie.
05:03 Hi, everyone. And thank you, Beata, for providing that great overview of the sector, which I think really puts into perspective the reason why we're all here today. And that is to gain a better understanding of some of the compliance requirements of a service provider who's licensed with FSRA. So as Beata mentioned, my name is Stevie Madder, and I am the Senior Manager in the Health Service Provider sector here at FSRA. We've received feedback from numerous stakeholders recommending that our supervision efforts should be focused on educating the sector. So back in November, FSRA republished the Health Service Provider Quick Guide to Compliance, which was our first step in our commitment to education. The quick guide provides an overview of some of the obligations of a service provider under the insurance act, it's regulations, and FSRA rules. The quick guide focuses on the most common areas of non-compliance that we've seen year over year since the licensing regime began in 2014.
06:11 I can appreciate that these compliance expectations are scattered among various regulations and guidelines. There's regulation 90/14, the SABS, the HCAI guideline, the fee rule. And that can present challenges for service providers and principal representatives. So the intended purpose of the quick guide, and really the goal of today's webinar, is to walk you through the common areas of non-compliance that we keep seeing as outcomes of our compliance reviews, and help everyone really understand what the expectations and regulatory requirements are. So today, I will be covering some of the important requirements related to reporting, business practices, and compliance. Next slide, please.
07:06 Service providers must report business changes to FSRA within five business days. So this includes changes to its mailing address, email address, telephone number, principal place of business, or any facility, branch, office, or location in Ontario. It's also very important for service providers to ensure that all information is updated in their FSRA account. Next slide, please.
07:40 Service providers are required to calculate and report an accurate SABS claim account to FSRA. Service providers must ensure that all information reported in their annual information return and any other information provided to FSRA correct, including the total number of SABS claimants. The total number of SABS claimants reported in the AIR must adhere to the calculation method prescribed in the fee rule. The fee rule states that the total number of SABS claimants is the total number of persons for which payment has been received for one or more listed expenses calculated per accident during the prior calendar year. So a person is counted more than once if they've been involved in multiple accidents. As you likely know, FSRA uses information from the health claims database to supplement and validate information reported in the AIR. So in recent AIRs, we have included, as a reference point, the total number of SABS claimants calculated for each service provider from the health claims database, which is really intended to be used as a reference point when validating the claimant count from your own records. Next slide, please.
09:07 So here we talk about the requirement to establish and implement policies and procedures. So your policies and procedures should be appropriate to the nature and volume of your business related to SABS. Policies and procedures must be designed to avoid the preparation or submission to an insurer of false, misleading, or deceptive forms, plans, invoices, documents, and other information by the service provider. Service providers are also required to conduct periodic reviews of documents submitted to insurers to ensure compliance with the legislation, applicable guidelines, and to ensure the reconciliation of billings. The review should be conducted in a manner and at a frequency that is appropriate to the volume of the service provider's business in connection with statutory accident benefits. And in any case, no less frequently than once every three months if the service provider was paid $50,000 or more for listed expenses by insurers in the calendar year before the review, or once every 12 months if the service provider was paid less than $50,000 for listed expenses by insurers in the calendar year before the review.
10:35 Service providers must also establish a process for addressing and resolving complaints from insurers in respect of the service provider's business systems and practices related to listed expenses. Next slide, please. Service providers are required to maintain an accurate HCAI roster. It is very important for service providers to keep their HCAI roster current and up to date. Service providers are required to remain in regular contact with the rostered health professionals active on their roster, even if they are not regular full-time employees. This is to ensure that these individuals know they are and consent to be associated with the facility. Within 10 days of an employee leaving the facility or upon receiving a request from a health professional to be removed from the HCAI roster, the facility must update their HCAI account with an end date for that provider. This ensures that no further OCF treatment forms will be submitted using the provider's credentials. Having an inaccurate HCAI roster creates an opportunity to misuse the credentials of a regulated healthcare professional. So ensuring that your business adheres to this requirement is very important. Next slide, please.
12:11 So all OCF 18s and OCF 23s must be signed by the regulated healthcare professional and the claimant. The only compliant practice for the submission of OCF 18s and OCF 23s is to complete the form, obtain the claimant signature, and then submit the form through HCAI. Next slide, please.
12:42 So all OCF 1s must be signed. They can either be signed by the regulated healthcare professional who provided the treatment, or the regulated healthcare professional can designate an authorized signatory to sign the OCF 21 on their behalf, provided they have given their consent. Service providers are required to keep a copy of the signed OCF 21 on file. So this can be either the original paper version or an electronic copy saved in PDF format. Next slide, please.
13:25 Service providers must take all reasonable steps to verify the identity of SABS claimants. So providers must verify that goods and services are being provided to the person who was involved in the motor vehicle accident. Next slide, please. So here we have included a list of resources available to service providers that you may find helpful. In the interest of time, I won't go through each item on this list, but I do encourage you to review these documents as there is a lot of important information and content that may be helpful to ensure that your business operations comply with applicable laws and help ensure the fair treatment for claimants who access SABS benefits. Next slide, please.
14:23 So this concludes the formal presentation on some of the compliance requirements of a service provider. I want to thank all of you for attending. We have hundreds of participants here today and a number of questions that I can see that have come in. If you have an individual circumstance that you have posted in the chat and would like to discuss, we encourage you to contact FSRA directly as we will not be addressing individual circumstances during this webinar. Any questions related to the content of the webinar that we do not take today, we will post on our website at a later date, and we will inform you when this has been done. With that said, let's move on to some of the questions. Okay. So one of the common questions that I can see here is there are instances where a provider has left my clinic, but I cannot deactivate them within the 10-day requirement because I'm waiting to submit outstanding invoices under their name.
15:33 So once a provider has been deactivated or given an end date in HCAI, the facility actually has six months to submit any remaining OCF 21s under the provider's name. For OCF 18s and OCF 23s, the provider's name will stop appearing in dropdown lists on their end date. But for OCF 21s, the provider's name will continue to appear in the dropdown list for six months after the end date. All invoices for that provider should be completed within six months. Okay. Another question here. Once policies and procedures have been established, are service providers required to conduct an annual review of their policies and procedures?
16:28 So although there's no legislative requirement to review your policies and procedures on an annual basis, we do recommend as a best practice that service providers are regularly updating their policies and procedures to accurately reflect their business operations. So whether that is annually or semi-annually or perhaps longer, we leave that up to the service provider to decide what makes the most sense for their business. Okay. Another question here. Each year, when calculating the total number of SABS claimants for my clinic, there is a discrepancy between my calculation and the calculation that FSRA provided from the health claims database. Why is this?
17:25 So that's a great question. And the health claims database claimant count offers a reference point that is intended to assist service providers in validating the claimant count from their own records. So the health claims database claimant count does not correspond precisely with the claimant count definition in FSRA's fee rule. It's based on approved invoices, not when payment was received. So it's not uncommon, and it actually makes sense for there to be a slight discrepancy between the two calculations. Ultimately, the intended purpose is to serve as a baseline so that if your number is way off, you can review your calculation method, review the fee rule, and ensure that you are calculating the claimant count correctly. Okay. So lots of great questions coming in here. Let me see here. Is the use of electronic signatures acceptable on OCF forms?
18:36 So an OCF-- or sorry, an electronic signature is a way to sign a document by inserting a unique electronic certificate. So for example, DocuSign. If your software provider is able to incorporate an electronic signature in this format, we would consider this to be an acceptable method to obtain the required signature. Okay. Another question here. Can you explain the difference between who can sign Part 4 and Part 5 of the OCF 18? So Part 4 of the OCF 18 is the treatment and assessment plan certification. So Part 4 can only be signed by a health practitioner who is recommending the treatment. The health practitioner that signs part four does not have to be employed or associated with the facility who provides the treatment. By signing the form, the health practitioner is stating that the treatment set out in the plan is reasonable and necessary for the injuries set out in, I believe, Part 6 of the form.
19:57 Now Part 5 is the treatment and assessment plan preparation and supervision. So Part 5 can be signed by a health practitioner or a regulated healthcare professional. So the health practitioner or the regulated healthcare professional signing Part 5 must be affiliated with the submitting healthcare facility as a healthcare provider. So I'll just give you a quick example of that. A registered massage therapist prepares an OCF 18 for a massage therapy. The massage therapist is required to sign Part 5 and supervise the treatment, but the massage therapist must arrange to have a health practitioner sign Part 4. So the health practitioner who signs Part 4 does not need to be associated with the facility. It could be the claimant's family physician. Or it may be signed by a health practitioner who is associated with the facility. For example, a physical therapist who works on staff at the facility.
21:06 Okay. Another question here. How and where do I report business changes to FSRA? So all business changes are completed through your FSRA account. The portal to log into your FSRA account can be found on our website. Your FSRA account is an important place which allows you to report business changes, update contact information, as well as file your annual information return, which, as a reminder, is due on March 31st this year. Let me just review some more questions here. Okay. This is a good one. Do you have a sample or a template of a policies and procedures manual? And what is the expectation for a sole proprietor versus a corporation in terms of creating a policies and procedures manual? So that's a great question. The answer is no. FSRA does not have a template for a policies and procedures manual. Part of that is because we understand that the business model of a sole proprietor versus a larger corporation differs significantly, and proportionality needs to be considered.
22:33 The regulation specifically indicates that policies and procedures must be appropriate to the nature and volume of the business. So that does take into account proportionality. As many of you likely know, FSRA has embraced a principles-based approach to regulation since its inception. So when applying principles-based regulation and an outcomes-focused approach, FSRA places greater reliance on a regulated entity senior management to internalize the requirements in order to achieve desired outcomes. So in the case of a service provider, this would be the principal representative. So principal representatives are responsible for demonstrating how their identified approach is effective in achieving adherence to the compliance requirements. Principal representatives should also communicate transparently and in a timely manner, the policies, processes, and practices, which have been adopted and implemented to demonstrate how the service provider is achieving the desired outcomes.
23:41 Okay. Lots of good questions. Another in here. Do I have to verify the identity of a claimant at each visit? So the regulation states that a licensed service provider must take all reasonable steps to verify the identity of each SABS claimant. So service providers must have a policy in place to verify the claimant's identification and be able to demonstrate that the process was followed. So one of the ways service providers can demonstrate ID verification is implement a checkbox on intake and visit forms, confirming their ID was verified. Principal representatives should implement a process which is reasonable in relation to their overall business operations. So this requirement is not meant to be an administrative burden. It's meant to protect claimants and help reduce the potential for fraud.
24:46 Okay. So a lot of great questions. And I'm so grateful to have been able to spend some time with all of you today. I personally want to thank all of you for taking the time to gain a better understanding of some of the compliance requirements of a service provider. I hope you found this information session helpful. Please take the time to review the resources that I shared earlier in the presentation once the webinar has been published because there is a lot of helpful content contained within those documents that will assist you and your business in understanding and complying with all legislative requirements. As a reminder, we will be posting the recording of this webinar and the responses to all relevant questions, both the questions I've answered here today and the ones that we didn't get to. You will also be receiving a survey with respect to this webinar. So please fill it out with your feedback so we know how we can improve, and what you would like to hear about in the future. Once again, you can always contact FSRA directly with any questions that you do have. Thank you for attending, and I hope you all have a great day.
Questions & Answers
FSRA response to audience questions
Q1: How and where do I report business changes to FSRA?
A1: All business changes are completed through your FSRA Account. The portal to login to your FSRA Account can be found on our website. In your FSRA Account you can report business changes, update or change contact information as well as file your Annual Information Return.
Q2: Each year when calculating the total number of SABS claimants for my clinic, there is a discrepancy between my calculation and the calculation that FSRA provided from the HCDB. Why is this?
A2: The Health Claims Database (HCDB) claimant count offers a reference point that is intended to assist Service Providers in validating the claimant count from their own records. The HCDB claimant count does not correspond precisely with the claimant count definition in FSRA’s Fee Rule. It is based on approved invoices, not when payment was received. It is not uncommon for there to be a slight discrepancy between the two calculations.
Q3: If a SABS claimant receives treatment over multiple calendar years, for the same accident, should Service Providers be counting this claimant multiple times?
A3: If treatment is provided to a claimant over multiple years, the Service Provider must count the claimant as 1 SABS claimant for each calendar year that payment was received.
Q4: Once Policies and Procedures have been established, are Service Providers required to conduct an annual review of their Policies and Procedures?
A4: Although there is no legislative requirement to review your Policies and Procedures on an annual basis we do recommend as a best practice that Service Providers are regularly updating their Policies and Procedures to accurately reflect their business operations.
Q5: Do you have an example or a template of a Policies and Procedures Manual and what is the expectation for a smaller vs. larger Service Provider in terms of creating a Policies and Procedures Manual?
A5: FSRA does not have a template for a policies and procedures manual. We understand that the business model of a smaller vs. larger Service Provider may differ significantly, and proportionality needs to be considered. The regulation indicates that policies and procedures must be appropriate to the nature and volume of the Service Provider’s business related to statutory accident benefits.
Q6: How many years must Service Providers retain Auto Insurance Claims Forms (OCFs)?
A6: Section 13 of O. Reg. 90/14 states that a licensed Service Provider shall keep any record related to an assessment, examination, report, form, plan, good or service performed or provided by or on behalf of the service provider related to listed expenses for at least six years after the date the record is created.
Q7: There are instances where a provider has left my clinic, but I cannot deactivate them within the 10-day requirement because I am waiting to submit outstanding invoices under their name. What should I do?
A7: Once a provider has been deactivated (or given an end-date in HCAI) the facility has 6 months to submit any remaining OCF-21s under the provider’s name. For OCF-18s and OCF-23s the providers name will stop appearing in drop down lists on their end-date. For OCF-21’s the providers name will continue to appear in the drop-down list for 6 months after the end date. All invoices for that provider should be completed within 6 months.
For issues pertaining to the process of issuing payment as a result of a judgement, that are beyond 6 months, FSRA encourages Service Providers to work with Insurers to manage these individual cases.
Q8: Do providers who work at multiple facilities have to be signed up in HCAI under each facility?
A8: Service Providers are required to maintain an up-to-date list in HCAI of all health professionals who provide services for the facility. This is commonly known as the HCAI roster. Providers must be on the HCAI roster of each facility they are working at.
Q9: Is the Dependent Provider Form and Affiliated Provider Form automatically provided to health professionals when they are registered to HCAI or are Service Providers required to get this signed?
A9: All Service Providers are required to retain a signed Dependent Provider Form or Affiliated Provider Form for each health professional on their HCAI roster. The forms are provided by HCAI upon the enrolment of the facility. The documents can be saved electronically, and the facility can print as many copies as needed. For more information or to print additional copies, please visit Health Claims for Auto Insurance (HCAI).
Q10: When should an OCF-21 be signed and where can we find the Authorized Signatory Consent form?
A10: The OCF-21 is required to be signed by the provider or authorized signatory prior to submission through HCAI. FSRA does not have a standardized authorized signatory consent form. It is the responsibility of the Service Provider to obtain and document consent.
Q11: Is the use of electronic signatures acceptable on OCF forms?
A11: An electronic signature is a way to “sign” a document by inserting a unique electronic certificate (ex. DocuSign). If your software provider is able to incorporate an electronic signature in this format, we would consider this to be an acceptable method to obtain the required signature.
Q12: Do I have to verify the identity of a claimant at each visit?
A12: Section 5 of O. Reg. 90/14 states that a licensed Service Provider must take all reasonable steps to verify the identity of each SABS claimant. Service Providers must have a policy in place to verify the claimant’s identification and be able to demonstrate that the process was followed. One of the ways service providers can demonstrate ID verification is implement a check box on intake and visit forms confirming that ID was verified. Principal Representatives should implement a process which is reasonable in relation to their business operations.
Q13: Why can’t a Regulated Health Professional (RHP) sign part 4 of the OCF-18 if they are the treatment provider?
A13: Part 4 of the OCF-18 must be signed by a Health Practitioner. The definition of a Health Practitioner is outlined in Section 3.(1) of O. Reg. 34/10
Q14: Can you explain the difference between who can sign Part 4 & Part 5 of the OCF 18?
- Part 4 is the Treatment and Assessment Plan Certification
- Part 4 of the OCF-18 can ONLY be signed by a Health Practitioner (HP) who is recommending the treatment
- The HP that signs Part 4 does not have to be employed/associated with the facility who provides the treatment.
- Part 5 is the Treatment and Assessment Plan Preparation and Supervision
- Part 5 of the OCF-18 can be signed by a Health Practitioners (HP) or a Regulated Health Professional (RHP)
- But the HP or RHP signing Part 5 MUST be affiliated with the submitting health care facility as a Health Care Provider.