FSCO Licensing Examinations Making Your Clinic Compliant. Wednesday, September 7, 2016

Transcription

1 FSCO Licensing Examinations Making Your Clinic Compliant Wednesday, September 7, 2016

2 Speakers Dr. Moez Rajwani (OCA) Wendy Horrobin (FSCO)

3 Agenda FSCO Update (OCA) Service Provider Examination: Moving from Education to Compliance (FSCO) Health Service Provider Licensing Toolkit (OCA) Questions

4 FSCO Update Common Traffic Impairment (CTI) Guideline Changes as of June 1 Definition of Catastrophic injuries

5 Medical and Rehabilitation Benefits Accidents on or after September 1, 2010 Non-Catastrophic Maximum of $50,000 or 10 years if over the age15 at date of loss, otherwise to age 25 Catastrophic Maximum of $1,000,000 Accidents on or after June 1, 2016 Non-Catastrophic Maximum of $65,000 (including attendant care benefits) or 260 weeks (5 Years) if over age 18 at date of loss, otherwise to age 28 Catastrophic Maximum of $1,000,000 (including attendant care benefits)

6 Case Management Services Accidents on or after September 1, 2010 Non-Catastrophic Not Available Catastrophic Available (part of $1,000,000 medical and rehabilitation limit) Accidents on or after June 1, 2016 Non-Catastrophic Not Available Catastrophic Available (part of $1,000,000, medical rehabilitation and attendant care limit)

7 Attendant Care Benefits Accidents on or after September 1, 2010 Non-Catastrophic Maximum of $3,000 per month and $36,000 for up to 2 years after accident Catastrophic Maximum of $6,000 per month and $1,000,000 Accident on or after June 1, 2016 Non-Catastrophic Maximum of $3,000 per month and $65,000 (including medical and rehabilitation benefits) for up to 260 weeks (5 years) if over age 18 at date of loss, otherwise to age 28 Catastrophic Maximum of $6,000 per month and $1,000,000 (including medical and rehabilitation benefits)

8 Non-earner Benefits Accidents on or after September 1, 2010 Payable after 26 weeks at $185 per week if completely unable to carry on a normal life. Increases to $320 per week from 104 weeks after accident if a student within the 52 weeks prior to the accident. Benefits reduced by formula at age 65 (subject to 2 year minimum) Payable after age 16 for life Accidents on or after June 1, 2016 Payable after 4 weeks at $185 per week if completely unable to carry on a normal life. Payable after age 18 and for maximum of 104 weeks

9 Service Provider Examinations Moving from Education to Compliance Presenter: Wendy Horrobin

10 Introduction and Key Messages Financial sectors regulated by FSCO Our mandate Financial Services Commission of Ontario 10

11 Market Conduct Compliance Unit Activities Compliance Examinations o o o o o o Mortgage brokering compliance audits and sweeps Insurance, Pensions and support others (Licensing) Annual Statutory Examinations Develops the Auto insurance questionnaire and conducts consequential examinations Ad hoc examinations as required Service Provider Examinations Handle Inquiries (Complaints) Informal market intelligence gathering Support Life Insurance and mortgage broking Suitability Review Support work to review insurance solvency regulation Support Industry Reviews, i.e Credit Union Review Value Proposition: MCCU conducts risk-based field examinations, financial assessments and market conduct reviews of FSCO regulated financial sectors in order to ensure consumer protection and legislative compliance. Resources 3 Managers 24 Senior Compliance Officers Financial Services Commission of Ontario 11

12 Our Regulatory Role FSCO s Approach: Engage stakeholders Educate market participants to ensure compliance Encourage industry-based solutions Enforcement in cases of non-compliance Financial Services Commission of Ontario 12

13 Purpose & Scope of Examinations When Did Examinations Begin? FSCO began examinations of licenced Service Providers on December 1, 2014 (when the regulations came into effect) What is the Purpose of the Exams? Purpose is to ensure licenced Service Providers are in compliance with the Insurance Act and its regulations What is the Scope of the Exams? Scope is to ensure that licenced service providers have appropriate systems in place with respect to their operations and billing practices for Motor Vehicle Patients claiming Statutory Accident Benefits. We also look at the operation in its totality to assess suitability Financial Services Commission of Ontario 13

14 FSCO s Approach to the Examinations Having completed 780 examinations since inception of the regime, Compliance is now our focus, but also using the exams as an Educational Tool to help service providers establish practices and procedures in their day to day operations that will facilitate compliance. For Example: The Standards of Practice regulations state that Service Providers (SP s) have a duty to verify the identity of the individual whom it performs services for. Therefore, when FSCO is on-site, there is an expectation that SP s will ask for photo ID (drivers licence, health card etc.). If not, FSCO would recommend the service provider implement such a policy. Financial Services Commission of Ontario 14

15 Examination Details Who Will be Coming on Site? FSCO s Senior Compliance Officers (SCO s) will be performing the on-site examinations. If your business is selected for examination the SCO will contact you to set up a suitable time. They will ask you in advance for various items to start their analysis prior to their on site visit. How Long Does an Examination Take? Examinations take approximately 1 business day (approx. 8 hours). However, there is no need to close shop but FSCO recommends to keep your patient schedule light in order to respond to questions from the SCO. If your operation is very large, or we have difficulty obtaining information, it may have to be extended. Why was my Business Selected? FSCO is currently selecting business based on a risk analysis taken from the most recent AIR as well as complaints from Insurers and consumers. Financial Services Commission of Ontario 15

16 Examination Details How Can I Prepare for the Examination? If you are selected, you can prepare by readying the following materials: Legal entity information such as articles of incorporation and master business licence (where applicable). Information on staffing such as health discipline practiced, registration/certification numbers, start and end dates. Your current HCAI roster. Financial statements for past two years (note: the purpose of reviewing financial statements is to verify the responses provided in your licence application) Recent HCAI billing activities, for example, reports, statements, summaries. Policies and procedures regarding billing practices for MVA patients, and be prepared to demonstrate that they have been applied. Your staff knows about them. Completed OCF forms 18 & 23, 21. (The SCO will review to ensure the forms are completed in compliance with the regulations. Personal information will not be collected and need not be disclosed for the purposes of the review.) Your Principal Representative or other staff member should also prepare to demonstrate how your business accesses and undertakes billing procedures through HCAI or Patient Management Software. Financial Services Commission of Ontario 16

17 A Word Regarding Confidentiality The potential disclosure of any personal health information during the course of an examination is for the lawful purpose of conducting a compliance examination, authorized under section 443(1) of the Insurance Act. FSCO s on-site examinations of service providers are about ensuring compliance with billing and business practices only; there will be no gathering or recording of medical or personal information of patients or clinical notes. FSCO examiners, like all OPS employees, are required pursuant to the Public Service Ontario Act, 2006, to take an oath of office which requires them to swear or affirm that they will not disclose or share any information or document that comes into their knowledge or possession except as required by law. Financial Services Commission of Ontario 17

18 Summary of Findings So Far FSCO has identified several issues while performing on-site examinations, below are the top five findings: SP s not verifying the identity of the individual SP s do not have written policies and procedures in regards to their billing practices OCF Forms not signed by either RHP or patient Outdated HCAI Rosters Updates to original application via licensing portal required. Contact info, directors ** We track Incidental findings that help our understanding of the Auto Insurance Industry Financial Services Commission of Ontario 18

19 Staff Interviews The SCO s will interview yourself as the principle representative Looking at background, particularly if the PR is not an RHP How you supervise staff or any assistants who help with patients We interview clerical staff to understand their role We look at your physical space and ensure that it appears work actually takes place there We look at the surrounding areas for any other medical services, body shops, law offices and may ask if there are relationships with these entities ** We are looking to see that all staff are on the same page as to their role and the way in which the clinic is designed to run. ** We track Incidental findings that help our understanding of the Auto Insurance Industry Financial Services Commission of Ontario 19

20 Health Service Provider Licensing Toolkit for Examinations/Audits

21 Toolkit Contents The Role of the Principal Representative Periodic Reviews Submission of Forms to Insurers Submission of Invoices Resolving Complaints About Insurers Resolving Complaints From Insurers Record Keeping Retention and Security Responding to Requests for Information Insured Responding to Requests for Information Insurer Responding to Requests for Information FSCO Submitting/Maintaining Accurate Information Verifying Identity of the Insured Submitting/Maintaining Accurate Information Employee/Associated Provider Records Submitting/Maintaining Accurate Information False Misleading or Deceptive Information Referral Fees

22 Questions? Dr. Moez facebook.com /OntarioChiropracticAssocation