The Statutory Accident Benefits Schedule (SABS) in Ontario is in need of further refinement to prevent insurers from getting "papered over" with an overwhelming number of treatment plans and assessments — a major component of auto insurance fraud.
"There are still miles to go [in preventing accident benefits fraud], and [treatment plan] inundation is a good example," said Gregory Jones, claims manager for State Farm Insurance Company, who was a speaker at the IBC's 11th Annual Regulatory Affairs Symposium in Toronto on Oct. 27.
"There's nothing [in the SABS] that prohibits claimants from papering us with 50 treatment plans per claimant, and that's a tremendous impediment."
Jones shared a few examples of current medical fraud investigations. In one example, he presented a photo of a nicked car bumper. The slight scratch resulted in the submission of 66 treatment plans (OCF-18s) on behalf of two claimants, as well as 42 Applications for Approval of Assessments (OCF-22s) from two treatment centres, he said. The total cost of recommended assessments, treatment plans and assistive devices from the two assessment centres amounted to $214,929.01.
"We didn't pay," Jones said. His audience included representatives of Ontario's insurance regulator, the Financial Services Commission of Ontario (FSCO).
In another example of "papering over" an insurer, Jones discussed two medical providers associated with 125 State Farm claim files. The files involved 250 claimants in total, two people per file. The two health care facilities in question submitted 50 treatment plans per claimant, for a total of 12,500 treatment plans from these facilities, Jones noted.
"This is just an example of an abuse of process," he said. "The overwhelming submissions, 50 treatment plans per claimant, are ... designed to inundate claim managers, to lessen their opportunity to investigate the claim. They have six days to do this, and 10 days to do that: we're working under a very regulated environment here. That is an example of ‘papering' an insurance company."
"Just think about that: 50 treatment plans. How could the first treatment plan possibly have had a chance to be effective?"
At a cost of $1,500 to resist each treatment plan, Jones calculated that it would cost an insurer $37,000 to resist such an inundation of claims submissions.