In a CBC interview published on December 29, 2011, Dr. Donna Ouchterlony of the brain injury clinic at Toronto’s St. Michael’s Hospital said “insurance companies are declining more and more treatment plans.”
This trend was recognized by the Alliance of Community Medical and Rehabilitation Providers shortly after the last set of changes to the Regulation came into effect on September 1, 2010 when the Alliance started receiving reports of increased denial rates of requests for assessment and treatment. With these reports intensifying in the first quarter of 2011, the Alliance’s board decided to poll its membership. The results were surprising. Our membership reported that the denial rate for treatment requests increased from 12% before September 2010 to 29% in February 2011 when the survey was conducted. Statistics surrounding applications for assessments were at similar levels.
The findings were immediately reported to FSCO and at the meeting that followed we were assured that this trend would be monitored. The Alliance was requested to conduct a follow-up survey at the one-year anniversary of the reform – which we have recently completed. This survey was more comprehensive and included respondents beyond the Alliance’s membership. We had 900 individual respondents and 250 clinics representing disciplines from treatment to IE providers working with both MIG and non-MIG clients across the province.
The results were staggering. At the one-year anniversary, surveyed health care providers reported that about half their treatment plans have been denied since September 2010, in contrast to 17% before the regulatory changes. More surprisingly, only 52% of all such denied plans were subsequently sent for a second opinion with an IE provider. Our survey indicated that assessment denial rates (whether an IE was ordered or not) increased from 27% before the regulatory changes to 42% after the regulatory changes, representing a 55% rate of increase. Denials of treatment OCF 18s have skyrocketed from 11% before the regulatory changes to 42% afterward, representing a 282% rate of increase – even though both surveys were careful not to include MIG clients in these reports.
In order to confirm this worrisome trend we decided to obtain precise OCF-18 denial stats by going to the source – HCAI. However, after spending a month asking HCAI for the information, our request was declined. So much for transparency!
Since our survey confirmed that the percentage of approved OCF 18s remained unchanged when sent to an IE, there could be only one reasonable explanation for the rapidly escalating denial rate of OCF-18s.
When the regulation was changed in 2010 to make IEs optional, the intent was for adjusters to use this “power” to avoid mandatory IEs in instances where a prior IE had already been conducted. The Regulation calls for the insurers to provide a “medical and other reason” when denying an assessment or treatment request. However, our survey shows that insurers are providing “medical and other reason” in only 26% of cases. It seems that insurers are ignoring the purposeful check-and-balance that was put in place and are making medical decisions without having appropriate training in health care or consulting an IE provider. On a related note, 63% of the respondents also reported that insurers are asking IE assessors to conduct in-person assessments rather than paper reviews, even when the original request was for an assessment.
The significant backlog in the dispute resolution process (approximately 30,000 files) is a further barrier for injured people to access care. When IEs were mandatory and dispute resolution addressed files within 60 days, a denied assessment or treatment plan would have received near-immediate attention. However, with a mediation backlog close to 12 months, many clients give up their quest for help and end up developing chronic conditions. The survey uncovered three other disturbing areas: the MIG, the assessment cap and insurer conduct. With respect to the MIG, respondents pointed out that in as many as 39% of cases where clients are put into the MIG, insurers are doing so against the judgment of the claimant’s health care provider and without the use of an IE to substantiate the decision. Further, health care providers who treat MIG clients indicated that 70% of their clients need more than the initial $2,200 MIG allocation, but 40% of those get declined. They also report that 53% of their MIG clients need more treatment than can be provided under a $3,500 cap.
According to survey participants, the $2,000 assessment cap continues to be a problem for both treatment and IE health care providers. The top three situations where the cap is an issue relates to clients who are already designated catastrophically injured, clients with complicated medical histories and those living in remote areas. Those were followed by such disciplines as neuropsychology and speech-language pathology, which traditionally could not complete their assessments under the $2,000 cap.
Lastly, survey respondents have reported on a disquieting trend in connection with insurers’ payment of invoices for services that have been delivered on pre-approved basis. Health care providers report a significant problem in the collection of accounts receivable from insurers. These providers report that their over 90 and 120 days accounts receivable represent 23% and 16% respectively. In the past insurers have claimed that the delay was due to a large number of documents transmitted through HCAI. However, recent data published by the Anti-Fraud Task Force revealed that as of September 2011 the number of documents transmitted through HCAI is equivalent to the level experienced when only 20% of the current number of facilities were enrolled on HCAI.
The results of our second survey have now been delivered to FSCO, the Ministry of Finance and the Anti-Fraud Task Force. Many recent changes have been made to protect insurer interests. With the ball now in the hands of the regulator and the government, we will see if new measures will be put in place to protect the victims. Let’s hope that Dr. Ouchterlony’s brain-injured clients and other survivors soon start getting the help they desperately need.