The Financial Services Commission of Ontario (FSCO) has released a new Health Claims for Auto Insurance (HCAI) Guideline that addresses billing procedures. 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.
FSCO said it has received complaints from stakeholders regarding billing practices by health care providers, especially in the areas of frequency of invoicing, incomplete invoices and record keeping.
In relation to frequency of invoices, FSCO said 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.
The revised Guideline prohibits the submission of duplicate invoices and invoices for unapproved goods and services, a tactic that is sometimes used to obtain unearned payments from insurers. FSCO added that 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.
FSCO noted that 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.
A copy of the new Guideline can be found online. (PDF)