What the regulator’s review of auto insurance health care practitioners uncovered

Ontario’s insurance market conduct regulator took a closer look at how auto insurance health care providers are billing insurers through the province’s electronic billing system, and found that 27 medical health professionals on the billing roster have been sanctioned by their health regulatory colleges.

Of the 27 medical health practitioners who were sanctioned, most received a warning letter from FSRA for failing to comply with review criteria, a few opted to surrender their licenses, and one was escalated for enforcement action.

Of 127 individual health service providers (HSP) who were sanctioned by their health regulatory colleges in 2021-22, 27 appeared on the Health Claims for Auto Insurance (HCAI) roster of 90 licensed medical service providers, according to a recent Financial Services Regulatory Authority of Ontario (FSRA) report. 

In the grand scheme of things, of the 5,000 health care providers licensed by FSRA, this is a “nominal number,” Beata Morris, senior manager of market conduct-health service providers at FSRA tells Canadian Underwriter. 

There are approximately 7,000 health care facilities in Ontario with approximately 30,000 providers. Approximately 5,000 health care facilities are licensed by FSRA. 

HCAI is an electronic system for transmitting auto insurance claim forms between insurers and health care facilities in Ontario. Licensed HSPs submit invoices on behalf of claimants through the HCAI system and are paid directly by insurers. 

FSRA regulates the billing practices of licensed health service providers, says Morris. “That helps protect Ontario consumers to ensure their benefits and auto claims dollars are actually utilized for treatment with valid providers.” 

The most common areas of non-compliance identified by FSRA in its Health Service Provider 2021-2022 Market Conduct Compliance annual report are as follows:

• OCF-21 invoices not signed 
• policies and procedures are not established or sufficient 
• The service provider’s HCAI roster is outdated/inaccurate 
• incorrect calculation of Statutory Accident Benefits Schedule (SABS) claimants 

FSRA’s HSP market conduct team conducted three supervision initiatives: Phase 1 desk reviews focused on the first three bullet points above; Phase 2 desk reviews focused on the fourth bullet point; and sanctioned practitioner reviews concentrated on the actions of health care regulatory colleges during the 2021-22 fiscal year (April 2021 to Mar. 2022). Morris says FSRA conducts these reviews on an ongoing basis. 

During Phase 1, FSRA reviewed 30 medical health practitioners. Of them, seven licensed service providers were compliant with the review criteria (regarding office procedures and the roles of the practitioners), 19 were issued a letter of warning for failing to comply with regulatory requirements, three did not complete the desk review and opted to surrender their licence, and one was escalated for enforcement action. 

During Phase 2, FSRA found 170 licensed service providers (94% of those reviewed) were compliant with the criteria, eight were issued a letter of warning for failing to comply with regulatory requirements, and two did not complete the desk review and opted to surrender their licence. 

Moving forward, FSRA will use this data on non-compliance to focus on educating the HSP sector. 

“FSRAs oversight and supervisory activities are designed to foster compliance, but also awareness in the sector,” says Morris. “Part of fighting fraud and ensuring that people’s benefits are used appropriately — and that facilities are billing for benefits and for services that have been provided — means understanding how the system works.” 

FSRA is suspending also the licences of 106 health service providers who have failed to file their Annual Information Returns (AIR) between 2018-21, announced in a press release yesterday.

 

Feature image courtesy of FSRA