1) When you spoke of the $2,000.00 cap for assessments – does this mean that a physiotherapist for example can do an assessment and OCF-18 Form and charge more than $200.00? Or is the $2,000.00 cap pertaining only to Occupational Therapy and Neuropsychological Assessments?
Yes, a physiotherapist can do a physiotherapy assessment and charge more than the $200.00. In accordance with Section 25 (5) of the Statutory Accident Benefits Schedule (SABS), the insurer shall not pay more than $2,000.00 in respect of fees for any one assessment or examination. The legislation does not specify what type of regulated health provider can charge the $2,000.00. The $200.00 cap is just for preparation and submission of the treatment and assessment plan form itself as per the Professional Services Guideline No. 06/10.
2) If the clients’ are suffering from psychological problems, are they considered outside of the MIG?
No, not necessarily. The client may have certain psychological problems but they can still be placed within the Minor Injury Guideline (MIG).
There are two ways that this can be done. The first way is through the definition of “minor injury”, as it includes a phrase “…and any clinically associated sequelae.” This may include things such as depression, anxiety, and other psychological difficulties that go along with a sprain, strain, etc. The second way the injury may fall within the MIG is if “the impairment is predominantly a minor injury.” If a person has an injury such as a sprain, subluxation, or whiplash and has psychological problems, the injury may still be considered to be “predominantly” a minor injury.
3) What is the rule when there is no response within the 10 day turnaround time for OCF18′s submitted on HCAI?
The treatment and assessment plan is deemed approved when there is no response within the 10 business days.
As per Section 38(11)(2) of the SABS, the insurer shall pay for all goods, services and assessments and examinations described in the treatment and assessment plan form that relate to the period starting on the 11th business day after the day the insured received the application. The insurer would only be obligated to pay for any treatment provided on the 11th business day after it was submitted up to the day they respond. They can still respond late and deny the treatment and assessment plan.
4) What happens when a treatment plan by an Occupational Therapist is declined? How does the remuneration work with regards to our time?
If your treatment and assessment plan was denied for an occupational therapy assessment and you proceed anyways, the insurer has no obligation to pay your cost of assessment.
If your treatment and assessment plan for occupational therapy services is denied, we suggest you contact the client’s law firm to confirm the denial will be mediated. At this point, you can discuss options with the representative on how to be remunerated.
If a treatment and assessment plan is submitted for your assessment and approved, this should be paid regardless of if your subsequent treatment and assessment plan for occupational therapy services is denied.
5) Have you had any clients indicate that the adjuster has indicated that the only option for coverage of attendant care needs is for the client to hire a private agency and they have indicated that the family member is not able to provide the attendant care even though they can show economic loss?
No, that is a definite misinterpretation of the legislation. Section 19 of the SABS states that attendant care benefits shall pay for all reasonable and necessary expenses that are incurred by or on behalf of the insured person…
Section 3 (7) (e) provides the definition for ‘incurred’ follows:
Definition of Incurred: (7) For the purposes of this Regulation, (e) Subject to subsection (8), an expense in respect of goods or services referred to in this Regulation is not incurred by an insured person unless, (i) the insured person has received the goods or services to which the expense relates, (ii) the insured person has paid the expense, has promised to pay the expense or is otherwise legally obligated to pay the expense, and (iii) the person who provided the goods or services, (A) did so in the course of his or her regular occupation or profession, or (B) sustained an economic loss as a result of providing the goods or services to the insured person;
Also note Section 3 (7) (c) states:
“For the purposes of this Regulation, an aide or attendant for a person includes a family member or friend who acts as the person’s aide or attendant, even if the family member or friend does not possess any special qualifications;”
6) We have had adjusters put patients WITH fractures into the MIG, and others with dental injuries also into the MIG. Many IE assessors use templates that deny the treatment without actually assessing the patient. Without the rebuttal examinations what can we do?
We would suggest writing letters of concern to the insurer, describing their acts as constituting bad faith, outlining a summary of the client’s impairments and what will happen if the treatment/therapy is not provided to the client. Secondly, contact the representing law firm for assistance in disputing the MIG determination and proceeding to file for mediation if need be. Our firms’ position is that people with fractures do not fall under the MIG as it is not the intention of the MIG to include fractures.
7) What happens if a significant medical report comes in after the independent examiner denies the treatments?
Send the report to the insurer and ask them to reconsider their position in light of the new supporting medical documentation.
However, please note that you cannot force the insurer to reconsider their position. Reasonable adjusters will want to treat clients fairly and will reconsider their positions and forward the new reports to the IE assessor.
8 ) The amounts on the Form 1 are not in line with the actual market rates. Also, the $100.00 per week for housekeeping/home maintenance won’t cover the necessary services that would be rendered. How can the shortfall be addressed? For example, meal preparation alone would eat up the $100.00!
There is no question that Form 1 rates are not in line with market rates. All you can do is take the amount on the Form 1, pay an agency market rates, and have a family member make up the needed attendant care. If the person has a viable tort claim, the short fall can be claimed through ‘out-of-pocket’ expenses in the tort claim.
9) What do treatment providers do when an OCF-18 is put in “pending” in HCAI and left there for weeks? Is there any obligation by the insurer to take it out of “pending”? No notes are included by the insurer as to why the OCF-18 was put into “pending” in HCAI.
As per Section 38 (8) of the SABS, within 10 business days after the insurer received the treatment and assessment plan, the insurer shall give the insured person notice with approval or denial, and if denied, the medical reasons for denial of any of the goods, services, treatment, assessments, and or costs of them.
Treatment providers can go ahead with their treatment and assessment plan on the 11th business day from receipt of the plan by the insurer, as no appropriate response has been received. However, please keep in mind that the deemed approval ends upon receipt of a denial.
10) If a treatment and assessment plan is approved can the insurer refuse to pay the healthcare provider after services have been rendered (and invoices submitted) citing that the client’s benefits have been exceeded?
It is our firms’ position that the insurer has an obligation to keep track of all benefits paid. There is a strong argument to be made that the insurer has entered into a contractual agreement once they approve a treatment and assessment plan, and therefore are obligated to pay.
Also, please note that as per Section 50 of the SABS, the insurer must provide a written update of benefits paid to date every 12 months to the insured persons who are deemed Catastrophic, and every 2 months in every other case.
11) What happens if an adjuster does not provide the required medical reason for denial of benefits?
Our law firms would recommend writing a strong letter to the adjuster regarding their obligation to treat clients with the utmost good faith, as this is an improper denial and may constitute a claim for bad faith.
12) Are all law firms receiving updates on how and/or what to do with MVA cases and updates on HCAI? A couple I’ve worked with seem unsure?
There is no requirement on any law firm to maintain current with updates on MVA cases and HCAI. However, it would be expected that knowledgeable law firms would be aware of relevant statutory and regulatory changes, as well as FSCO bulletins.
13) Are the adjusters notifying the law firms that an insurer’s examination will be scheduled if a treatment and assessment plan is denied as not reasonable and necessary?
Yes. Our firms send letters to the insurer upon being retained, asking that they send copies of all correspondence to our attention. Once our firms are advised of the insurer’s examination, we send the client’s medical brief to the insurer to forward to the insurer’s assessor.
14) What is a lawyer’s responsibility to ensure that the client’s treatment providers are paid and paid within 30 days?
Our firms will assist treatment providers in recovering approved and incurred treatment expenses in a timely manner.
15) How do you respond to an adjuster who is unwilling to pay the $200.00 for the submission of the treatment and assessment plan, stating that the maximum they will pay is $70.00 as they feel that this is reasonable for the completion of a treatment and assessment plan?
Refer the adjuster to the Professional Services Guideline No. 06/10, which indicates the maximum amount payable for completion of a treatment and assessment plan is $200.00. Also provide the adjuster with details of your billing rate and time spent to justify the $200.00 fee.
16) When a multi-disciplinary assessment is required to determine appropriateness for admission to a Chronic Pain service, is the cap of $2000.00 applied per assessor or for the multi-disciplinary assessment as a whole?
The legislation says $2,000.00 for any one assessment. Every insurer may interpret the treatment and assessment plan for a multi-disciplinary assessment differently.
We have seen multi-disciplinary assessments being approved more frequently when a separate treatment and assessment plan is submitted for each assessment.
Also, while it is important that appropriate assessments are conducted, we would encourage assessors to limit the number of assessments required in order to preserve our client’s scarce medical and rehabilitation benefits.
17) When a treatment and assessment plan is denied, the insurer used to pay the cost of the re-assessment & cost of treatment plan; after September 2010 most of them are denying payment. Are they supposed to be paying for this portion on a denied treatment plan?
As stipulated in Section 25 (1) 3 of the SABS, the fee for the Treatment and Assessment Plan (OCF-18) is payable only if any one or more of the goods, services, assessments or examinations described in OCF-18 have been: i. approved by the insurer, ii. deemed by the SABS to be payable by the insurer, or iii. determined to be payable by the insurer on the resolution of a dispute in accordance with sections 279 to 283 of the Insurance Act.
Therefore, the answer is no. The insurer does not have to pay the cost of completing the treatment and assessment plan if the plan is denied.
18) I have been charging $70.00 for the completion of treatment and assessment plans which I thought was the cap as per FSCO Professional Services Guideline June 2010. Am I undercharging? Should I be charging $200.00? Has this changed? The $200.00 is the maximum charge for completion of a treatment and assessment plan. This is not a flat rate.
Refer to the Professional Services Guideline No. 06/10, which indicated the maximum amount payable for completion of a treatment and assessment plan is $200.00
19) What happens when a treatment plan is denied and we have sufficient medical reports to indicate that patient should be placed outside of the minor injury guidelines however the independent examiner decides that the patient ‘s injuries still fall under the MIG even after they review the supporting medical evidence which states otherwise? Contact the law firm to confirm that an application for mediation will be filed to dispute the determination. As well, an accident benefits specialist may be able to negotiate the client being placed outside of the MIG.
20) Are you deeming OCF-18′s “review required” status as approved on HCAI if the 10 days has passed?
As per Section 38 (8) of the SABS, within 10 business days after the insurer received the treatment and assessment plan, the insurer shall give the insured person notice with approval or denial, and if denied, the medical reasons for denial of any of the goods, services, treatment, assessments, and or costs of them.
Treatment providers can go ahead with their treatment and assessment plan on the 11th business day from receipt of the plan by the insurer, as no appropriate response has been received. However, please keep in mind that once a denial is received, the approval ends subsequently.
21) It can be common for patients with multiple and serious orthopaedic injuries to be discharge home until they have completed a series of orthopaedic surgeries and are strong enough to participate in an inpatient rehabilitation program. In the recovery period at home, they will need in home physiotherapy interventions. Especially with the new $50,000.00 accident benefits cap, the associated travel expenses for the service professional can be prohibitive, especially if the claimant lives outside an urban setting. Is there any possibility that professional fees related to travelling to a claimant’s home may not be billed to the accident benefits $50,000.00 cap? Professional fees regarding travel time are treated the same way as any other. It will be billed from medical and rehabilitation benefits. We would encourage treatment providers to charge a minimum for travel expenses, given the fact that there is a scarcity of medical and rehabilitation funds.
We would also suggest that in areas where service providers are able to see more than one client on any given day they can pro-rate their travel costs.
22) In the document you are speaking of for the definition of catastrophic impairment, did you say that behavioural issues from a brain injury does not have any bearing on deeming someone catastrophic? If yes, this is a major issue with safety and SHOULD have a bearing on deeming an injury catastrophic.The medical review panel’s recommendations can be found on our website. There are numerous recommendations in their report regarding catastrophic determination, which are too numerous to review here. We encourage you to review the report and advise the panel of any concerns and comments you may have, to help the process.
23) For physiotherapists providing services for complex injuries to a client prior to being determined catastrophic, may we invoice retroactively for the hourly SABS fee differential, once they have been deemed catastrophic?Consult the law firm to see if the differential can be recovered from a lawsuit.
24) Does the committee suggest how to deal with ABI clients who refuse admission to a Facility possibly due to lack of awareness and need continued community rehab support OR how to deal with waiting lists for inpatient rehab programs? The medical review panel did not touch on this issue. Please see the attached FSCO report.
25) How does the legislation affect assistive device purchases?Assistive devices fall under medical and rehabilitation benefits. As per Section 38 (2), if a medical or rehabilitation benefit is reasonable and necessary as a result of the impairment sustained by the insured, an insurer will pay up to $250.00 or less per item without needing an approved treatment and assessment plan.
Also note, there are lesser funds available as the limits for medical and rehabilitation benefits have dropped to $50,000.00 from $100,000.00 after September 1, 2010.
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