How FSRA plans to tackle auto insurance health care provider fraud

A two-year supervision plan for health service providers (HSP), released today by the Financial Services Regulatory Authority of Ontario (FSRA), aims to protect consumers’ rights by delivering supervision and education to higher risk auto insurance HSPs.

Higher risk service providers are defined as those “more likely to either bill for services not provided, or bill for services that are not provided by a regulated health professional,” Beata Morris, senior manager of market conduct, health service providers at FSRA, told Canadian Underwriter.

The plan will help FSRA maintain fair and reasonable auto insurance rates for consumers.

“If a clinic is billing for services not provided, everybody’s rates go up because everybody has to pay more,” she said. “It’s ensuring that services are being billed appropriately for services that are being provided.”

HSPs that receive direct payment from auto insurers for benefits claimed under the Statutory Accident Benefits Schedule (SABS) may be selected by FSRA for examination under one of the three streams:

Insurer-Initiated Examination (IE) Reviews – If you are a service provider conducting examinations to help an insurer determine if an insured person is, or continues to be, entitled to a benefit.
Focused Compliance Reviews – If you are a service provider who has never been examined by FSRA.
Sanctioned Practitioner Reviews – If you are an HSP with a sanctioned practitioner listed on your Health Claims for Auto Insurance (HCAI) roster.

First, IE Reviews are “the assessments that insurers request claimants to attend to receive a medical opinion or information with respect to claimants’ injuries and recommendations from the health service provider with respect to entitlement to benefits,” said Morris.

Next, FSRA identified several areas of non-compliance in its Health Service Provider 2021-2022 Market Conduct Compliance annual report, including:

OCF-21 invoices not signed
Policies and procedures not established or sufficient
Service provider’s HCAI roster is outdated/inaccurate
Incorrect calculation of SABS claimants

Going forward, Focused Compliance Reviews will work to increase compliance and awareness in the HSP sector by reminding participants of their requirements.

“We’re looking to specifically focus on facilities that we’ve not previously reviewed, to get a better idea of what the compliance rates out there are and what to look at,” said Morris.

Lastly, Sanctioned Practitioner Reviews will be conducted to ensure practitioners sanctioned by their health regulatory colleges are suitable for work under their HSP.

“In instances where a provider is sanctioned by the college or their license is revoked, we have lists of those sanctions and revocations, and we’ll review them to ensure that the services that are being billed are actually by licensed providers,” said Morris.

While supervision is one element to FSRA’s plan, the regulator also aims to focus more on education for the non-compliant HSP sector.

“We’ve identified our first approach, which is supervision…but we’ve also identified that there’s a need for a better understanding of the regulatory requirements,” said Morris. “We’ve done some initial feedback and initial discussions with respect to webinars and exploring educational opportunities to assist the sector with compliance.”

“Early in the new calendar year, we will be providing webinars to service providers to give them a better understanding of the requirements, answer any questions they may have and assist with compliance.”