Purpose

The purpose of this document is to provide existing and new Health Service Providers (“HSP”) with information about the duties, responsibilities and regulatory compliance requirements expected of a licenced HSP.

Introduction

FSRA regulates the billing practices of service providers licensed by FSRA to help maintain fair and reasonable auto insurance rates for consumers. Health Service Providers are typically medical practitioners, health and rehabilitation clinics, as well as providers of assessments and examinations. HSPs serving patients receiving accident benefits due to auto insurance claims should be aware of contractual obligations between a claimant and their insurer.

FSRA’s objects in the Health Service Provider sector:

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Regulate and supervise Health Service Providers to ensure financial safety and fairness for Ontarians.

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Engage in dynamic principles-based and outcomes-focused regulation by monitoring and evaluating developments and trends.

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Promote honesty and credibility in the industry by deterring deceptive or fraudulent conduct, practices, and activities.

FSRA will regulate the Health Service Provider’s business systems and billing practices as outlined in the Standards for Business Systems and Practices regulation in Ontario Regulation 90/14 and section 288.4 of the Insurance Act.

Disputes regarding an insured person’s entitlement to statutory accident benefits or the amount of statutory accident benefits to which an insured person is entitled are the sole jurisdiction of the Licence Appeal Tribunal. Please visit the following website for more information: https://tribunalsontario.ca/lat/automobile-accident-benefits-service/

Did you know?

Instances of allegations related to Regulated Health Practitioners will be directed to the appropriate Regulatory College or professional association.

Should my business apply for a FSRA Health Service Provider licence?

What is Health Claims for Auto Insurance (HCAI)?

Health Claims for Auto Insurance (HCAI) provides a mandatory and common platform for health care facilities to submit Treatment and Assessment plans (OCF-18), Treatment Confirmation Forms (OCF-23), and their associated invoices (OCF-21), as well as Assessment of Attendant Care Needs forms (Form 1) to auto insurers for review and adjudication.

Should my business apply for a FSRA Health Service Provider Licence?

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Businesses that wish to invoice auto insurers through HCAI and be paid directly by auto insurers for specified listed expenses1 will need a licence.

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A Health Service Provider licence will authorize the business to receive direct payments from auto insurers for specific listed expenses.

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Unlicensed Health Service Providers must still submit all Ontario Claims Forms (OCF) forms through the HCAI system. However, they will not be able to receive direct payment from auto insurers.  Insurance companies will directly pay the claimants that receive treatments from unlicensed Health Service Providers. Claimants will have to reimburse the clinic for services rendered.

Did you know?

Once a licence has been issued by FSRA, it will continue indefinitely, as long as the licensee complies with the law, files an Annual Information Return (AIR) every year on time and pays the Annual Regulatory Fee (ARF) on time.

Duties and responsibilities of the Principal Representative

The Principal Representative (PR) is the person designated by the Health Service Provider to be the primary contact with FSRA. The PR will be primarily responsible for the Health Service Provider's licence and compliance with the law.

The PR has the authority to make decisions on behalf of the licensee. The PR is responsible for communicating with FSRA about matters related to the licence and the licensee's compliance with the Insurance Act (Ontario), as described in Ontario Regulation 349/13.

The Principal Representative's duties are to:

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File the Annual Information Return and pay the Annual Regulatory Fee by March 31st of every year (unless otherwise advised by FSRA).

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Ensure that the licensee and every person authorized to provide specified goods or services on the licensee’s behalf complies with the Insurance Act.

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Ensure that the licensee's business systems, practices and supervision of the licensee's operations follow the law and are developed with integrity and honesty.

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Make recommendations to the licensee regarding changes in its business systems, practices, and the supervision of its operations, as necessary.

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Take reasonable steps to implement a system of supervision that ensures that all requirements under the law are met.

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Provide attestations on the licensee's behalf about the licensee and about the licensee's compliance with the Act, as may be required by the CEO.

Only the Principal Representative is allowed to file the Annual Information Return on behalf of the Health Service Provider.

Duties and responsibilities of HSPs

Having a Health Service Provider Licence with FSRA means that Health Service Providers may be subject to an on-site examination by FSRA at some point. FSRA’s processes for reviewing licensees will emphasize a risk-based approach. This risk-based approach utilizes complaint data, licensing information, AIRs, Health Claims Database data and sanctioned practitioner information.

An important part of maintaining a Health Service Provider licence is meeting the standards for business systems and practices described in O. Reg 90/14. According to these requirements, among other things, all licensees must:

Reporting

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File an Annual Information Return (“AIR”) and pay the Annual Regulatory Fee (“ARF”) by March 31st of every year, unless otherwise advised by FSRA.

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Report changes in the Health Service Provider’s business to FSRA within five (5) business days. These changes include modifications in contact information, principal representative, directors, officers, or partners.

Business Practice

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Respond to insurer requests within ten (10) business days for certain types of information. This information includes the Health Service Provider’s FSRA licence number and specified details about individuals who have been authorized to provide goods or services on its behalf.

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Do not submit invoices or other documents to HCAI if the Health Service Provider suspects the presence of inaccurate, false, or misleading information.

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Retain any record related to goods and services provided by or on behalf of the Health Service Provider related to listed expenses for at least six (6) years from the date the record was created. Records can be retained in electronic or paper form but must be retrievable within five (5) business days of receiving a request.

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A licensed Health Service Provider shall establish and implement appropriate policies and procedures considering the nature and volume of the Health Service Provider’s business related to statutory accident benefits.

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Healthcare professionals must abide by their respective college’s professional standards and code of conduct.

The HSP regime was implemented in December 2014 and is FSRA’s newest sector. Since the regime has been in effect for over six (6) years, FSRA expects an improvement in filing rates across the regime. If Health Service Providers do not file their respective AIR and pay the ARF, it is likely that their FSRA licence will be revoked. Auto insurers rely upon FSRA’s public registry to identify Health Service Providers that are licensed and can be paid directly for listed expenses.

Compliance

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Ensure that each facility, branch, or location is enrolled with Health Claims for Auto Insurance (HCAI).

Comply with the requirements of the HCAI Superintendent Guideline.

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Maintain an up-to-date list in the HCAI system of those health professionals who provide services for the facility. This is commonly known as the HCAI “roster”. When a health professional ceases to provide services for the business, the facility is required to update their HCAI account with an “end date” for that provider. This ensures that no further OCF treatment forms or invoices will be submitted under the former provider’s credentials.

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Use approved OCF forms only, if the CEO has approved a form under the Statutory Accident Benefits Schedule (SABS).

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Conduct periodic reviews of documents submitted to insurers (as described in the regulation) to ensure compliance with the legislation and applicable guidelines, and reconciliation of billings.

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Treatment plans (OCF-232 & OCF-183) must be signed by both SABS claimants and practitioners.

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Verify patient identification data for every claimant. Health Service Providers must have procedures in place to verify the claimant identification and be able to demonstrate that the process was followed.

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Invoices (OCF-214) must be signed by an authorized individual. The authorization process should be well-documented and acknowledged by the authorized individual.

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A licensed service provider shall not submit an invoice for a listed expense to an insurer using any name or licence number other than the name and licence number that correspond to the service provider’s licence.

Did you know?

OCF forms are FSRA approved forms and must be utilized in all cases, whether you are a FSRA licensee or not.

Reminder about HSP licencing fees

Fee Item

Explanation

Cost

One-time licence fee

This one-time licensing fee covers the cost of assessing the application for satisfaction of the regulatory requirements and determining whether the applicant qualifies for a licence.

$337

Annual Regulatory Fee (ARF):

This annual regulatory fee covers the cost of regulating the Health Service Provider sector. The regulatory fee is proportional and varies based on the size and nature of the applicant’s business.

The annual regulatory fee is calculated based on the following formula:

A + B

Where:

“A” = $128 x the “Number of locations”5

“B” = $15 x the “Number of SABS Claimants”6

Note: If your regulatory fee is $5,000 or more, please mail a cheque, money order or bank draft (with payment remittance attached) payable to “FSRA” or to the “Financial Services Regulatory Authority of Ontario” to the following address:

25 Sheppard Avenue West, Suite 100, Toronto, ON, M2N 6S6

Important

To ensure uninterrupted access to direct billing, FSRA strongly advises that the Principal Representative of the HSP comply with all the duties and responsibilities outlined in this document.

Frequently asked questions

For a list of frequently asked questions, please see the following website: https://www.fsco.gov.on.ca/en/service-providers/faqs/pages/default.aspx


1“Listed expenses” are the assessments, examinations, reports, forms, plans, goods, and services that need to be billed through the Health Claims for Auto Insurance (HCAI) system using an Auto Insurance Standard Invoice (OCF-21).
2 OCF-23 Treatment Confirmation Form: form used by facility and/or associated Provider to inform an Insurer that treatment for an injured person will commence within the Minor Injury Guideline.
3 OCF-18 Treatment and Assessment Plan: outlines assessments or examinations that a facility or associated Provider requires for ongoing management of the Claimant's recovery.
4 OCF-21 Auto Insurance Standard Invoice: form used to invoice automobile insurers for the medical and rehabilitation goods and services.

5 Number of locations = The maximum number of physical locations at which you conducted business that gave rise to listed expenses in the prior calendar year (January 1 to December 31).  If you were not licensed until the current calendar year, use the number of physical locations for which the Health Service Provider received a licence from FSRA.
6 Number of SABS Claimants = Total number of persons for which payment has been received for one or more listed expenses (calculated per accident) during the prior calendar year. A person may be counted more than once if they have been involved in multiple accidents.