Proposed Regulatory Model For Healthcare and Assessment Facilities

The Auto Insurance Anti-Fraud Task Force delivered a status update today to the government. I will be providing a review of the report on this blog over the next week. Today I will review a proposed model for regulating healthcare and assessment facilities that operate in the Ontario auto insurance sector.

I worked on the model on behalf of the Task Force and hope that readers of this blog take the time to review it and provide the Task Force with feedback.

The proposed regulatory model is intended to:

• Create barriers for healthcare/assessment facilities that wish to practice in the Ontario auto insurance system based on a "fit and proper" test.
• Sanction participants for fraudulent acts including denying the ability to operate in the Ontario auto insurance sector.
• Evolve HCAI into a regulatory tool to support market conduct regulation and a mechanism to sanction fraudulent behaviour.
• Designate a "regulator" with appropriate powers to oversee the market conduct of healthcare/assessment facilities and coordinate with the health regulatory colleges on issues dealing with professional misconduct. The proposed regulator would be FSCO.

All providers of medical and rehabilitation goods and services as well as providers of independent medical assessments would be covered by this model including:

• Multi-disciplinary treatment facilities
• Regulated health professions who are sole practitioners
• Assessment facilities supporting insurers and claimants
• Unregulated providers who provide specialized medical and rehabilitation services to claimants (e.g., vocational rehabilitation, case management, home modifications)

There would be 3 types of licences issued by FSCO. Licences would be not be transferable.

• Facility Licences for large providers (based on HCAI billings)
• Restricted Licences for providers not owned or operated by a regulated health professional
• General Licenses for small providers

Facility and Restricted Licences would involve a paper application process while the General Licence would involve an electronic filing process similar to the HCAI registration process. Licences would be valid for one year and would be renewed by submitting an acceptable Annual Information Return which would be an electronic filing process that would update the information on file at FSCO.

Facilities would be required to maintain business practice standards set out by FSCO, a combination of Regulations, the existing HCAI terms and conditions, and Superintendent's directives/guidelines. The regulatory health colleges would continue to be responsible for clinical practice standards of the regulated health professions working in the licensed facilities.

Some of the new proposed business standards include:

• No owner, operator, director or practitioner may have a felony conviction (going back 5 years)
• Facility is independent of all insurance companies, claims adjusting companies, personal injury lawyers and paralegal operating in the auto insurance sector
• Clinical Director of a facility with a Facility Licence must be a regulated health professional
• Clinical Director must be on-site for a minimum of 50% of the facility's operating hours
• If the facility is conducting third party medical exams, all practitioners conducting exams must have at least five years of applicable clinical experience and attest that they working within their scope of practice
• Facility will file all fees with FSCO and will not invoice for amounts that unreasonably exceed amounts charged by others for similar goods and services

FSCO will be provided with new authorities with respect to licence applicants and licensed facilities:

• Deny a licence application for failing to meet the required standards
• Investigate complaints regarding improper business practices of licensees
• Conduct risked based audits of licensees
• Issue orders to licensees regarding deficient business practices
  
• Suspend licenses of facilities and/or individuals for fraudulent practices or for ongoing deficient business practices
• Pass on to the appropriate authority when suspected criminal activity is uncovered
• Inform HCAI and Regulatory Colleges of facilities and health professionals that have been sanctioned
• Inform the public of enforcement action

HCAI would have a role in the licensing process. HCAI would be expected to develop a quarterly attestations regarding accuracy and appropriateness of bills submitted through HCAI. Facilities that failed to complete the attestations would have their billing privileges suspended.