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Health Service Providers: Building a Culture of Compliance
In response to increasing auto insurance claims costs due to fraudulent activity in the sector, in December 2014, FSCO began licensing service providers who bill auto insurers directly for medical and rehabilitation services they provide to injured auto accident benefit claimants, and regulating the billing practices related to those services.
FSCO recognizes that entities in newly regulated industries face a learning curve, and require time and support to understand and adopt new compliance requirements. That’s why it continues to engage and educate the 4,600 licensed providers it oversees to help build awareness and ensure they understand their business and billing practice obligations under the law. In 2016-17, FSCO also increased its focus on enforcement to improve compliance. Overall compliance rates doubled to 33 per cent in 2016-17 from 15 per cent in 2015-16.
FSCO continues to work with both service providers and stakeholder groups to increase awareness and understanding of service provider compliance responsibilities. It strengthened transparency and raised awareness of key compliance concerns among sector stakeholders by publishing reports based on the results of on-site examinations and Annual Information Returns. FSCO also sent several newsletters by email to all registered service providers to share information about the importance of compliance and consequences of non-compliance.
FSCO staff are attending meetings with various health service associations to build relationships, better understand the health service sector, and ensure service providers are clear on FSCO’s compliance expectations. FSCO will also soon hold its first Market Conduct Symposium for the service provider sector to share compliance expectations and information about increased enforcement activity.
“We recognize that patient care is paramount for health service providers. We’re working with them as they get more used to their added regulatory requirements.”
Esau Habibulla, Senior Compliance Officer
Number of Health Service Providers Licensed by FSCO 2015-2017, as at March 31
Description of Number of health service providers licensed by FSCO image
HEALTH SERVICE PROVIDER LICENSING ACTIVITY
| ||2016-17 ||2015-16 |
Individuals|| || |
New Licences Issued || || |
| Service Providers, Sole Proprietors||168||274|
Corporations|| || |
New Licences Issued || || |
| Service Providers, Corporations||275||339|
| Service Providers, Partnerships||23||22|
FSCO undertook 200 on-site service provider examinations in 2016-17 and introduced re-examinations after 90 calendar days for service providers with examination findings of non-compliance. This strategy has proven effective: of the 51 re-examinations conducted in 2016-17, 100 per cent of service providers were in compliance by the re-examination date. In the 2016-17 on-site examinations, the most significant reason for enforcement action was due to inappropriate business or billing practices. Examples include Ontario claims forms not being signed by the regulated health care provider and/or the patient, not having written or established policies and procedures in place for billing and business practices, and not communicating business changes to FSCO in a timely manner as required by law.
Going forward, FSCO will keep working to build a culture of compliance in the service provider sector, and strengthen its focus on enforcement.
Health Service Provider Compliance Rates 2014-15 to 2016-17
Description of health service provider compliance rates image
HEALTH SERVICE PROVIDER ENFORCEMENT ACTIVITY
|Letters of warning||3||–|
Administrative monetary penalties || || |
| Orders issued||4||–|
| Amount ordered||$31,685||–|
As awareness increases of service providers’ obligations under the law, consumers, insurers and other organizations have used FSCO’s complaint process to ensure compliance. Complaints against service providers rose significantly in 2016-17 to 45, up from 7 in 2015-16.
The majority of complaints (23) received in 2016-17 were made by insurers. The single largest cause of service provider complaints (63%) related to being billed for services that were not provided.
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