On September 1, 2010 there was a change in auto insurance regulations.  As a result there have been many questions and concerns from patient’s regarding these auto insurance changes.  In September 2011, the Coalition of Auto Insurance Reform representatives, which includes the Regulated Health Professionals Association including chiropractors, massage therapists, registered nurses, social workers, psychologists, physiotherapists, dentists, speech language pathologists and occupational therapists who are involved in both the assessments and treatments within the auto sector, requested a survey be completed by all of its member organizations.

KEY FINDINGS:

  • Health care providers who treat minor injury patients indicated 70% of the patients needed more treatment than was currently under the Minor Injury Guideline and of those who requested approval Treatment Plans to access the additional $1,300.00, 39% were declined access to further care by the insurer.
  • The SABS, in their most recent changes, while removing the requirement for Insurer Examinations, have added a provision that insurers would need to provide a medical reason for denial. Results indicated that in a significant number of cases the denied treatment plan did not include a medical reason for denial. For those who completed the $3,500.00 worth of medical benefits available for their patients with minor injuries, 53% indicated that further intervention was required, but due to the cap, were not able to provide treatment for their patients.
  • Pre-reform statistics identified that 17% of OCF-18s were denied completely.  Following the reform, 48% of the OCF-18s requesting treatment was now denied. Fifty-three percent of these would refer to an Insurer’s Examination.
  • The survey found billing issues had become a growing challenge in the industry since the reform took place. The survey highlights that where the insurer has approved the OCF-18 and invoices are submitted, 36% of invoices are 60 days overdue.

PROBLEMS:

The most common issues that have been highlighted during recent conversations with chiropractors and communication providers of the OCA are as follows:

  • Patients that do not meet the definition of minor injury are not given an opportunity to exit the minor injury definition and no specific medical reason is being provided.
  • When Insurer’s Examinations are being completed, the majority of them are not being completed by peers, specifically, chiropractors.
  • Delayed invoices that are not being paid and continuous issues with insurance companies with respect to responding to correspondence and phone calls.

RECOMMENDATIONS:

  • When you receive a denial from an OCF-18 Treatment Plan that does not provide a medical reason, the claims adjuster should be immediately contacted and you should request that a medical reason be provided.
  • One of the areas that has seen a significant change since September 2010 is the utilization of chiropractic evaluators to conduct independent assessments. In the past, the Auto Insurance Regulation had an unfair, deceptive act, which indicated that assessors should have the necessary training, education and experience to conduct these evaluations. The government, as of September 1, 2010, has made Insurer’s Examinations discretionary and the regulations no longer have any criteria on how to select an IE provider. This issue has been highlighted to the government and directly to insurance companies by different health care professional associations and industry organizations such as the Alliance of Community Providers and the Canadian Society of Chiropractic Evaluators. How insurer’s respond to this is yet to be seen…

In response to the survey, the Coalition, of which the OCA is a member, has made the following recommendations to the government:

  • When an insurer denies a request for the claimant to be excluded from the minor injury cap due to not meeting the definition of a minor injury, the insurer should provide appropriate medical reasons for denial. Where there are no medical reasons for the insurer provided with a third party peer evaluation, the request and the claimant’s condition, should occur.
  • Approval for the additional funds ($1,300) within the minor injury cap should be a routine matter unless there is a very clear indication that goods and services are not reasonable and necessary.
  • Implement and enforce penalties to insurers who do not pay health care providers on those files that have been approved or deemed approved. Penalties should include, at the minimum, the reinstatement of the 2% late penalty by insurers and a mechanism to ensure compliance with the penalty.

CONCLUSIONS

We have been told that, in most cases, a phone call to the adjustor will likely resolve the situation and it is important that members try to communicate with adjustors on a regular basis. The biggest feedback received from the insurance industry is the lack of communication between health care providers and their patient’s insurance companies.

SOURCE: OCA NEWS May 2012