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New service provider licence for all Ontario medical rehabilitation clinics

The following is a summary of the major changes to the Insurance Act concerning the operation and reimbursement of clinics and attendant care facilities through the Ontario Accident Benefits scheme.

The relevant sections of the Insurance Act have already gone through two major changes, one in 2013, the other on February 1, 2014. Also another set of changes has been proposed this year and is currently being considered by the Parliament of Ontario. It is unclear if or when this final set of changes will become the law.

According to the 2013 Bill passed through parliament, insurance companies are only permitted to reimburse medical clinics and attendant care providers for treatments of an insured, if they hold a valid ‘service provider’s licence’. In other words, if a clinic does not hold that licence, then any treatment of an insured is not chargeable as a ‘listed expense’, and insurance company does not have to pay for such treatments under accident benefits insurance policy. This aspect is meant to deal with fraudulent practices of certain health clinics, particularly in the GTA, that will overbill insurers or will bill for unperformed services.

Under section 288.4 of the Act, holders of a service provider’s licence are required to comply with such standards as may be prescribed by regulation with respect to their business systems and practices, and to comply with certain standards of integrity in the management of the licensee’s operations. Licensees are also required to submit invoices to the applicable insurer (or to such other person or entity as the insurer directs) for payment of listed expenses.

The Financial Services Commission of Ontario (FSCO) is in charge of licencing and regulating clinics under the Ontario Accident Benefits Scheme.

On February 1, 2014, a further change was made to the Ontario Accident Benefits Scheme, potentially reducing the amount of money payable to an attendant care provider, where such an attendant care provider is not acting in the ordinary course of his employment.

While previously a non-professional attendant care provider received payment in accordance with the amounts laid out in the Assessment of Attendant Care Needs Form. Now a non-professional attendant Care provider can receive payment only for the income loss sustained directly as a result of providing the attendant care in question. These changes will not affect professional attendant care providers.

Currently, FSCO will begin accepting licensing applications on June 1, 2014 and the licensing deadline will be set for December 1, 2014. All clinics must be registered with FSCO by December 1, if they wish to continue receiving money from insurance.

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