Sample - 2017 Service Provider Annual Information Return (AIR)

Please note this sample is for reference only. It may be slightly different than the AIR you see when you log in to FSCO Account.

 

Step 1 of 9 – Introduction

 

Welcome to the 2017 Annual Information Return (AIR). The Financial Services Commission of Ontario (FSCO) uses the information you provide in the AIR to help identify, assess and monitor risk in the service provider sector, and to calculate annual regulatory fees.

 

The deadline to file the AIR and pay the fee is by March 31, 2018.

 

Don’t wait until the last minute! You can file anytime between January 24 and March 31, 2018. At a minimum, please review Steps 1 and 2 as soon as possible, as you may be required to update information or have questions that may take several business days to respond.

 

The reporting period is January 1 to December 31, 2017; you must file even if you did not conduct any business during the reporting period. 

BEFORE YOU PROCEED

  • Only the Principal Representative of the licensed service provider can attest to the information in the AIR.
  • If the AIR is not filed and the fee paid by March 31, 2018, FSCO may immediately suspend or revoke your health service provider licence. You may also be subject to an administrative monetary penalty. Any missed deadline will be noted on your file, which may increase the level of future enforcement action taken by FSCO.

Throughout this document, unless otherwise specified, “you” refers both to:

 

  • the licensed business on whose behalf you are completing this AIR, and
  • you as the Principal Representative.

WHAT YOU NEED TO FILE THE AIR

Standard Technical Requirements

 

  • Recommended internet requirements include:
    • Internet Explorer 11
    • secure high-speed internet connection
    • ensure JavaScript is installed
    • enable cookies and pop-ups
    • enable 128-bit encryption and security protocol TLS 1.2.

More information is available on the FSCO website.

 

Other Requirements

  • Information from the previous calendar year (January 1 – December 31, 2017): Number of business locations and number of Statutory Accident Benefit Schedule (SABS) claimants.
  • Note: These are required to calculate your Annual Regulatory Fee. Valid form of payment are as follows:
    • For regulatory fees under $5,000, a valid VISA, MasterCard, or debit card must be used.
    • For regulatory fees of $5,000 or more, a certified cheque or money order payable to the Minister of Finance is required, and should be submitted by March 16, 2018 in order to be received on/or before March 31.

Please note: Consistent with FSCO’s role in protecting the public interest pursuant to s.3 (a) of the Financial Services Commission of Ontario Act, 1997 and as part of the Ontario government’s mandate to reduce fraud in the automobile insurance industry, FSCO collaborates with other organizations, including fraud prevention organizations and law enforcement agencies, to help combat fraud. Please be advised that the information you provide in this AIR may be shared with organizations that may collect and use this information, only as reasonably necessary, to enable them to carry out the purposes of detecting, suppressing and preventing fraud.

READY TO FILE THE AIR?

The AIR will take you around 30-60 minutes to file. However, you can save your work at any time and come back to it later.

 

If you have finished reading Step 1, please confirm your agreement with the following to proceed to Step 2:

 

I, Principal Representative of the licence number indicated below, confirm that the information that will be provided in this Annual Information Return will be true to the best of my knowledge and belief.

 

Step 2 of 9 – Confirm business information

 

Please identify whether the following information is correct or incorrect.

 

If any information has changed:

 

  • Please proceed to the supplementary change application in your FSCO account.
  • You will only be able to proceed with the AIR once you have been notified through the FSCO account that the change application has been processed.

You will not be able to proceed with the AIR until all Step 2 questions have been confirmed and/or an updated application has been submitted.

 

  • Licence number
  • Licensed business (business legal name)
  • Business ownership type
  • Ontario mailing address for the business
  • Principal Representative for the business
  • Principal Representative email address
  • All directors, officers for the business
  • All partners for the business:
  • Registered Trade Names for the business:

The above business information is correct   Y             N   

 

Step 3 of 9 - Confirm/edit business information


 

Please identify whether the following information is correct or incorrect, or add new information if required.

 

  • Principal Representative phone number
  • Principal Representative fax number
  • Principal Representative belongs to the following Regulatory Colleges (Regulated Health Professional governed by a College under the Regulated Health Professions Act, 1991 or the Ontario College of Social Workers and Social Service Workers under the Social Work and Social Service Work Act, 1998) as at December 31

 

Step 4 of 9 – Business profile 

 

Please review and update if necessary.

 

Franchise

Business has been granted a licence to do business under a franchisor’s trademark:   Yes / No

Enter franchise name:

 

Website

The business uses the following website(s) for marketing or advertising to SABS claimants:

Include both sites and accounts that are used for marketing/advertising exclusively to SABS claimants, and those directed more widely. Exclude external websites that display ads you have purchased, and external service listings.          

▢  N/A

 

Social media

Please list all social media accounts (e.g. Facebook, Twitter, LinkedIn, etc.) used for marketing or advertising to SABS claimants:

Exclude social media accounts that display advertisements you have purchased.

▢  N/A

 

Business – Owners  (Corporations only)

Please indicate the total number of owners of the business, including any Directors and Officers, as at the end of the reporting period (December 31, 2017):

1 to 10:

More than 10:

 

As at the end of the reporting period (December 31, 2017) were there owners who were not Directors or Officers of the business?

▢  Yes

 

Please list owners who were not Directors or Officers of the business. If there are more than 5, please list only the top 5 owners, based on the greatest percentage of ownership.

Owner name:              Phone number:

 

▢   No – There are no other owners

▢   N/A – Other – Provide details:

 

Service delivery

Based on amounts billed through HCAI, please indicate how your services to SABS clients are predominantly delivered:

▢   Facility - clients come to the business’s location(s)

▢   Community - provider goes to client

▢   Balance between facility and community

▢   Remote coordination of goods and services (by telephone, email, etc.)

▢   Other (Please describe):

Please provide an estimate of the average hours per week that the Principal Representative was on site at the business service location(s) during the reporting period (January 1 – December 31, 2017):

Comment (optional):

 

*Please note that when an ‘estimate’ is requested in the AIR, precise figures are not required. However, for the purposes of attesting that the information provided is true to the best of the principal representative’s knowledge and belief, FSCO is seeking a reasonable estimate and expects you to be able to explain how the estimate was arrived at, if requested, for example during an on-site examination.


 

Step 5 of 9 - Membership information

Accreditation from Health Care Accreditation Organizations

  • On December 31, 2017 did you or the business have an active accreditation status from either of the following Health Care Accreditation Organizations:
  • CARF Canada:
    • y/n
    • Please indicate expiry year.
  • Accreditation Canada:
    • y/n
    • Please indicate expiry year.

Preferred provider

Was the business a member of a Preferred Provider Network (PPN) on December 31, 2017? (y/n)

 

Please specify the purpose of the membership in the PPN.

 

  • Patient treatment
  • Insurer-initiated examinations
  • All of the above

Please indicate with which insurers you had a PPN membership.

 

Step 6 of 9 – Business activity information and annual regulatory fee calculation

Annual regulatory fee calculation

Why is there a fee?

The Annual Regulatory Fee covers the yearly cost of regulating the service provider sector. The fee is due no later than March 31, 2018.

 

How is this calculated?

The Annual Regulatory Fee is calculated based on the data provided in the AIR for the prior calendar year (January 1 – December 31, 2017).

 

The Annual Regulatory Fee is calculated based on the following formula:

 

A + B

 

"A" = $128 x the "Number of Locations" of the licensee.

 

"B" = $15 x the "Number of SABS claimants" of the licensee.


 

The answers to the following questions will be used to calculate your annual regulatory fee: 

For the reporting period (January 1 to December 31, 2017), please indicate:

 

Number of Locations ______  The maximum number of physical locations at which the licensee carried on business that gave rise to listed expenses in the prior calendar year (January 1 to December 31, 2017) during the period in which the service provider held a licence from FSCO.

 

Note: Only locations registered with the Health Claims for Auto Insurance (HCAI) system count as business locations.

 

Number of SABS claimants ______  The 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.

 

Note: Neither FSCO nor Health Claims for Auto Insurance (HCAI) has the ability to generate a list of your Statutory Accident Benefits Schedule (SABS) claimants; it is your responsibility.

 

Motor vehicle accident claims business

During the reporting period, what percentage of the business’s patients were SABS claimants:       

▢  1% - 20%

▢  21% - 50%

▢  51% - 70%

▢  71% - 100%

 

Business services

For the reporting period (January 1, 2017 to December 31, 2017), please indicate which services your business provided to SABS claimants, and indicate the portion of the total amount billed through HCAI for each.

 

Service type

Percentage of total amount billed through HCAI for that service

 

More than 15% of the total amount billed through HCAI

 

Up to 15% of the total amount billed through HCAI

 

Not applicable – service type is not provided by the business

Treatment

Insurer-initiated exams

Provider-initiated assessments

Goods and supplies

Other –  please provide details: ____

 

Comment (optional):

For treatment services ONLY, please provide an estimated percentage of the business’s SABS claimants who were deemed by their insurer to have sustained a catastrophic impairment:

▢   None

▢   31-25%

▢   26-50%

▢   51-75%

▢   76-100%

 

Please provide an estimated percentage of the business’s SABS claimants who were treated ONLY under the Minor Injury Guideline:

▢   None

▢   31-25%

▢   26-50%

▢   51-75%

▢   76-100%

 

If you have indicated no billings through HCAI for the period, please indicate for which SABS services the licence was obtained.

 

  • Treatment
  • Insurer-initiated exams
  • Provider-initiated assessments
  • Goods and supplies
  • Other – please provide details:

Regulated health professionals

For the reporting period (January 1 - December 31, 2017):

 

Select the types of goods and services provided by regulated health professionals on behalf of the business, that were billable through an OCF-21 (Auto Insurance Standard Invoice) in HCAI.

 

​Types of goods and services e.g.​Confirm​Remove - no longer provided by the business

​Chiropractic

▢​​▢
​Physiotherapy​▢​▢
​Psychology​▢​▢

 

Add additional types of goods and services provided by regulated health professionals on behalf of the business: 

 

Total number of regulated health professionals providing goods or services:

 

Note: "regulated health professional" refers to a member of a profession governed by a College under the Regulated Health Professions Act, 1991, or by the Ontario College of Social Workers and Social Service Workers under the Social Work and Social Service Work Act, 1998.

 

Non-regulated health professionals

Select the types of goods and services provided by non-regulated health professionals on behalf of the business that were billable through an OCF-21 (Auto Insurance Standard Invoice) in HCAI.

 

​Types of goods and services e.g.​Confirm​Remove - no longer provided by the business

​Physiotherapy

▢​​▢
Case management services​▢​▢

 

Add additional types of goods and services provided by non-regulated health professionals on behalf of the business that were billable through an OCF-21 (Auto Insurance Standard Invoice) in HCAI.

 

Total number of non-regulated health professionals providing goods or services:

 

Note: "non-regulated health professional" refers to an individual who provides one or more listed expenses whose profession is not subject to regulation under the Regulated Health Professions Act, 1991 or the Ontario College of Social Workers and Social Service Workers under the Social Work and Social Service Work Act, 1998.

 

Step 7 of 9 - Business systems and practices

Policies and procedures

You are required to establish and implement policies and procedures that are appropriate to the nature and volume of your business related to statutory accident benefits.

 

Section 17 of Ontario Regulation 90/14 [New Window] requires policies and procedures that are designed to avoid the submission of misleading information to an insurer and to prevent the business from facilitating such activities by others. Communication of policies and procedures to all staff and providers involved in SABS billings also helps the business avoid facilitating or carrying out non-compliant practices.

 

Please indicate the month and year your policies and procedures were last reviewed, and the title of the individual who conducted the review:

 

​Month​Year​Not reviewed - Please explain why​Title of the person who conducted the review

 

 

​On December 31, 2017:​Yes​No​N/A​Comment
​Were the policies and procedures documented, in either written or electronic form?​▢​▢​▢
During the reporting year (January 1 - December 31, 2017), did the business ensure that:​Yes​No​N/A​Comment
​New staff received training regarding the policies and procedures.▢​▢​​▢
​Existing staff received training regarding any changes to policies and procedures▢​▢​▢​

 

Verifying patient identity

You are required to verify the identity of each Statutory Accident Benefits Schedule (SABS) claimant.

 

Please confirm that you are aware of this requirement:

▢  Yes

▢  No

▢  N/A

 

If no, or not applicable selected, please provide details: _______________

 

Note: Ontario Regulation 90/14 requires the service provider to “take all reasonable steps” to verify the identity of each individual. What constitutes all reasonable steps and due diligence is dependent on the unique set of facts specific to each case. The service provider should satisfy themselves as to identity, have a verification process that is reasonable for a given set of circumstances, and be able to demonstrate that the process is documented and was followed in a particular case, if and when required.

 

For example, the service provider’s protocol could establish that if the service provider has verified a client’s identification at the initial visit, sees the same client on a regular basis, and recognizes him or her by sight, it may not be necessary to examine the person’s identification at each subsequent visit. However it is up to the service provider to be able to prove that it was not necessary should an issue arise.

Signatures on OCF forms

 

Permitting a Statutory Accident Benefits Schedule (SABS) claimant to sign a blank or incomplete OCF form is unlawful as it is considered an unfair or deceptive act or practice.

 

​Does the business ensure that:​Yes​No​N/A​If so, or not applicable, plese pvovide details
​Claimants are only ever provided completed OCF forms to sign​▢​▢​▢
​Forms are signed by both the claimant and the required provider(s) before being submitted through HCAI.​▢​▢​▢

 

Attendance records

During the reporting period, did the business maintain attendance records for Statutory Accident Benefit claimants?

▢  Yes

▢  No

▢  N/A - please provide details:

 

If Yes, please indicate the type of records below:

▢  Sign-in sheet for all patients at reception

▢  Individual sign-in sheet located at reception

▢  Individual sign-in sheet located in patient file

▢  Other - please provide details

 

Referrals to the business

From what source does your business receive the most referrals:

Please provide referral source other than walk-ins, social media, mailings and other marketing and advertising, etc.

▢  Law firms

▢  Physicians/specialists

▢  Hospitals

▢  Insurers for Insurer Examinations (list all insurers)

▢  Other patients

▢  Affiliated service providers (i.e. same Principal Representative, owners, director/officer, partner, etc.)

▢  Other SABS service providers

▢  Firms providing vehicle towing, repair, storage

▢  Other - please provide details

▢  N/A - No referrals were made to the business during the reporting period

 

Referrals made by the business to others

To whom does your business provide the most referrals:

▢  Law firms

▢  Physicians/specialists

▢  Hospitals

▢  Affiliated service providers (i.e. same Principal Representative, owners, director/officer, partner, etc.)

▢  Other SABS service providers

▢  Other - please sprovide details

▢  N/A - No referrals were made by the business during the reporting period.

 

Reminder: While referrals are not prohibited, Ontario Regulation 0/700 defines receiving or paying a referral fee in connection with statutory accident benefits claims as an unfair or deceptive act or practice.(Some exceptions apply.)

 

Annual financial statements prepared by the business

During the reporting period (January 1 - December 31, 2017, did the business prepare annual financial statements?

▢  Yes

▢  No

▢  N/A

If no, or not applicable, please provide details:

 

If yes, select the type of financial statements prepared:

▢  Audited

▢  Notice to Reader - Compilation Engagement

▢  Review Engagement

▢  Internally Prepared Externally Reviewed

▢  Internally Prepared Internally Reviewed

 

Enter the month and day of your business's fiscal year end:

 

Step 8 of 9 - Billing information and practices
Use of electronic/digital signatures

 

During the reporting period, did the business use electronic/digital signatures on OCF forms?

▢  Yes

▢  No

 

If yes, please select all that apply:

 

▪  Claimants apply their own electronic/digital signature to OCF 18 / OCF 23 forms

   ▢  Yes

   ▢  No

       ○  If yes:

       ▢  Using a stylus
    ▢  Other (Please describe):

    ▪  Providers apply their own electronic/digital signature to OCF forms    

   ▢  Yes

   ▢  No

            ○  If yes:

            ▢  Using a stylus

            ▢  Using a stored scanned image of their name/signature

            ▢  Using a digital signature that protects the document from subsequent changes and includes
                a timestamp

            ▢  Other (Please describe):

▪  A stored electronic/digital signature of the provider is applied, on behalf of the provider, by someone other than the provider (e.g. office administrator)    

   ▢  Yes

   ▢  No

            ○  If yes:

            ▢  Using a stored scanned image of the provider's name/signature

            ▢  Using a digital signature that protects the document from subsequest changes and includes a timestamp, on behalf of the provider

            ▢  Other (Please describe):

▪  Other use of electronic/digital signatures on OCF Forms    

   ▢  Yes

   ▢  No

            ○  If yes:

            ▢  Please describe:

▪  OCF Forms are signed physically and then saved in electronic format (e.g. a scanned PDF is retained)    

   ▢  Yes

   ▢  No

 

Security and integrity of records


You are required to take all reasonable steps to ensure your paper and electronic records are secure and cannot be falsified.

 

During the reporting period, did you ensure that paper and/or electronic records were secure and could not be falsified?  

▢  Yes

▢  No

▢  N/A

  

OCF submissions through HCAI

Provide the total number of people (including providers, administrative staff and others) who had access to enter invoices and/or treatment forms through HCAI on December 31, 2017:

 

Use of HCAI reports for periodic reviews

You are required to conduct periodic reviews under O. Reg 90/14 Section 12 [New Window].

 

Are you aware of the Monthly Financial Statement Reports that are available in HCAI that can be used to assist in a periodic review? 

▢  Yes

▢  No

▢  N/A

 

Are the HCAI Monthly Financial Statement Reports useful for periodic reviews?

▢  Yes

▢  No

▢  N/A
Comment (optional):

 

Use of the Monthly Financial Statements for the periodic review is not a legislative or regulatory requirement. Please see HCAI’s website [New Window] for more details. The Monthly Financial Statement is a report available in HCAI to manage HCAI treatment and billing information. It describes everything invoiced by your Health Care Facility in the previous month and can be used to verify that your previous month’s invoices are accurate and complete.

 

Rostered health professionals list in HCAI
You are required to keep your rostered health professionals list up-to-date by adding an end-date to the rostered health professional’s record when they are no longer employed or working with the facility.

Is your rostered health professionals list in HCAI currently up to date?

 

  • Yes;  No;  N/A – other
  • Please provide details

OCF- Use of signature
During the reporting period:

 

  • Have your rostered health professionals authorized the use of their signature on OCF-21 invoice forms by other individuals within the business? (Y/N)
  • If Yes: Is this authorization documented, including an effective date? (Y/N)

OCF- Billings
What was your total dollar amount of OCF-21 billings submitted to auto insurers for the reporting year:

 

Statutory declaration requests made under Statutory Accident Benefits Schedule 46.2 (1) 2 [New Window]
Insurers may request a statutory declaration from a provider as to the circumstances that gave rise to an invoice, including particulars of the goods and services provided. Service providers are required to give the insurer the information requested within 10 business days of the request. 

 

During the reporting period (January 1 – December 31, 2017):
How many times did your business receive a section 46.2 request for a statutory declaration from an insurer in response to an invoice?

 

▢  No requests

▢  1 to 10 requests

▢  More than 10 requests

 

Note: Count each request received. For example, count as 2 if 2 requests are received for a single claimant or a single treatment plan.

 

Please list the top 3 insurers who requested a section 46.2 (1) 2 statutory declaration during the reporting period:


             Insurer
1._____________________
2._____________________
3._____________________

 

List as many insurers as applicable.

 

Step 9 of 9 - Suitability

 

FSCO continuously assesses the suitability of service providers to remain licensed in Ontario. Suitability requirements refer to businesses, as well as to their Principal Representative, and rostered health professionals. As the Principal Representative, you are required to provide information about yourself and about the business.

 

What offences must be disclosed?

Offences under federal statutes such as the Criminal Code, the Controlled Drugs and Substances Act and its predecessor the Narcotic Control Act, the Food and Drugs Act, the Income Tax Act (Canada), the Immigration and Refugee Protection Act (Canada), the Competition Act, and the Copyright Act are criminal offences and must be disclosed.

 

Charges and convictions under provincial statutes must also be disclosed. Such statutes include the Independent Health Facilities Act, the Regulated Health Professions Act, 1991, the Provincial Offences Act, the Insurance Act, the Mortgage Brokerages, Lenders and Administrators Act, 2006, the Registered Insurance Brokers Act, and the Human Rights Code, or their equivalent in other provinces.

 

If charges are pending or you have pleaded guilty or been found guilty of an offence under the above statutes, or any others, this information must be reported even if you were given an absolute or conditional discharge.

 

You do not have to disclose:

 

  • any offence for which a record suspension (formerly known as a pardon) has been granted under the Criminal Records Act (Canada) and has not been revoked. Record suspensions are not automatically granted merely because of the passage of time. Nor is a record suspension automatically granted because you applied for one. Written confirmation from the National Parole Board of your granted record suspension is the only way to ensure a record suspension has been granted.
  • convictions under either the Youth Criminal Justice Act or its predecessors, the Young Offenders Act or the Juvenile Delinquents Act.
  • findings of guilt for traffic infractions such as speeding or parking violations.

If you answer "Yes" to any question in this section, please provide a full explanation in your own words in the window that will open. Please retain all relevant documentation for future reference.

 

Suspension, refusal or revocation of licence or registration
Principal Representative and business

 

  • During the reporting period, did you or the business have a licence or a registration suspended or conditions imposed under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
  • During the reporting period, did you or the business have a licence or a registration refused under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
  • During the reporting period, did you or the business have a licence or a registration revoked under any regulatory regime in Ontario or elsewhere? Y/N – please provide details
  • During the reporting period, were you or the business fined or were any monetary penalties imposed by any regulatory regime in Ontario or elsewhere excluding FSCO? Y/N – please provide details

Suspension, revocation or refusal of licence or registration
Rostered health professionals

 

  • During the reporting period, did any individuals on your rostered health professionals list in HCAI have a licence or a registration suspended, revoked or refused, or have a fine or monetary penalty imposed under any regulatory regime in Ontario or elsewhere? Y/N – please provide details

Bankruptcy
Principal Representative and business

 

  • During the reporting period, did you or the business declare bankruptcy, or make a voluntary assignment in bankruptcy; or are you or the business currently party to bankruptcy proceedings? Y/N – please provide details

Pleaded or found guilty of an offence or subject of charges
Principal Representative and business

 

  • During the reporting period, did you or the business plead guilty or were you or the business found to be guilty of an offence under any law of any province, state or country; or are you or the business currently the subject of charges? Y/N – please provide details

Sued in a lawsuit
Principal Representative and business

 

  • During the reporting period, were you or the business successfully sued in a lawsuit based, in whole or part, on fraud, theft, deceit, misrepresentation, forgery, or professional negligence? Y/N – please provide details

Complaints
Principal Representative and business

 

  • During the reporting period, was a complaint made against you or the business to any regulatory body in a Canadian jurisdiction? Y/N – please provide details

 

Review and Attestation

IMPORTANT:

 

Before making the attestation and submitting the AIR please make sure that you have thoroughly reviewed all answers for accuracy. Once you have digitally signed the Attestation, no further changes can be made.

 

Providing false, misleading or incomplete information to FSCO in this AIR is an offence under the Insurance Act. Every individual convicted of an offence under this Act is liable to a fine of up to $250,000.

 

Additionally, providing false, misleading or incomplete information to FSCO in this AIR could form grounds for the Superintendent to suspend or revoke the service provider licence, or issue an administrative monetary penalty.