With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing a new Health Claims for Auto Insurance (HCAI) December 2011 Guideline – Superintendent’s Guideline No. 03/11 (new Guideline). This new Guideline replaces the previous Health Claims for Auto Insurance September 2010 Guideline – Superintendent’s Guideline No. 07/10 (current Guideline) that was issued in September 2010.
This new Guideline applies to specified documents that are delivered on or after December 1, 2011, regardless of the date of the accident to which they relate.
As part of Ontario’s crackdown on auto insurance fraud, the new Guideline has been revised to provide direction on billing procedures.
FSCO has received complaints from stakeholders regarding practices by health care providers surrounding billing procedures in the following areas:
Frequency of Invoicing
Under the current Guideline, health care providers are not restricted in the frequency with which they can submit invoices, which contributes to a high volume of paper for insurers. To address this issue, the new Guideline requires that invoices be submitted only once a treatment plan has been completed, or once every 30 calendar days if the treatment extends beyond a month.
The submission of incomplete invoices by health care providers in regards to extended health care benefits (EHCB) can create “double dipping” situations where the provider receives payment from both the EHCB carrier and the auto insurer. To address this issue the new Guideline stipulates what information is mandatory on the OCF-21.
Duplicate Invoices and Invoices for Non-approved Goods and Services
The submission of duplicate invoices and invoices for unapproved goods and services is a tactic that is sometimes used to obtain unearned payments from insurers. To address this issue, the new Guideline prohibits these practices.
Repeated and/or deliberate submission of duplicate invoices and invoices for non-approved goods and services may be considered by HCAI to constitute a contravention of HCAI’s terms and conditions and result in suspension or revocation of the health care provider’s access to HCAI.
A section on recordkeeping has been added to the new Guideline as an extension of Property and Casualty Auto Bulletin A-02/11, Insurer Rights and Responsibilities to Challenge Questionable or Abusive Claims.
Updates to Appendix 3 Validation Rules
There have also been changes made to the Appendix 3 Validation Rules in order to provide more clarity for the user.
Future Amendment to OCF-21
Effective July 1, 2012, FSCO will issue an amended OCF-21 form that will provide that the “Plan Number” of the OCF-18 or OCF-23 to which the OCF-21 refers is a mandatory field. This is the unique number generated by the HCAI system when the OCF-18 or OCF-23 to which the OCF-21 refers is submitted, and will enable insurers to properly reconcile invoices.
This future amendment is being announced at this time to allow all affected users to make any required changes to their systems to accommodate this change.
The Guideline is issued pursuant to section 268.3 (1) of the Insurance Act for the purposes of the SABS.
Copies of the HCAI Guideline
A copy of the new Guideline is attached. The new Guideline is also available on FSCO’s website at www.fsco.gov.on.ca and will be published in a forthcoming edition of The Ontario Gazette.
Chief Executive Officer and
Superintendent of Financial Services
November 8, 2011