Differential Diagnosis

This two-part article discusses the real, potential and anecdotal effects of Ontario’s auto insurance reforms on access to health care for auto injury claimants. Part I of the article, reproduced below, analyzes the impact of the Minor Injury Guideline (MIG) and the Minor Injury Cap from the perspective of health care providers. Part II of the article, to be published in February 2011, will analyze the new $50,000 med-rehab benefit, independent examinations and attendant care benefits. 

The Coalition Representing Health Professionals in Automobile Insurance Reform is in ongoing discussions with insurers, the Insurance Bureau of Canada and FSCO to address a number of emerging issues related to the Sept. 1, 2010 implementation of Ontario’s auto insurance reforms.

A great deal has been written about what is contained in the Ontario insurance reforms. This article presents some concerns raised by the rehab community about the impact of the reforms on people’s health care. Some openly question whether the new Statutory Accidents Benefits Schedule (SABS) might be in contravention of the Canadian Health Act principles of universality (access to same level of care) and accessibility (reasonable access to health care). It also raises questions as to the power of adjusters to make judgments related to people’s health care needs.

This article raises the questions, but does not purport to answer them. Rather, its purpose is to shed some light on these emerging issues in an attempt to promote further discussion, monitoring, and problem-solving among all the stakeholders. 

Minor Injury Guideline (MIG) & Minor Injury Cap

Claimants suffering minor injuries as defined in the new SABS are only entitled to receive a maximum of $3,500 for medical and rehabilitation expenses. These include medications, assessments, treatment and any other reasonable goods and services such as an ambulance and/or assistive devices. 

Within this $3,500, a pre-approved amount of $2,200 for the implementation of the Minor Injury Guideline (MIG) provides treatment blocks and payable fees without the need for prior insurer approval. There is $400 allowed for supplemental goods and services.

If a claimant requires more treatment than that outlined in the Guideline, an OCF-18 (Treatment and Assessment Plan) must be submitted with a total cost of goods and services of no more than the difference between the $3,500 and the $2,200 — in other words, $1,300 minus the cost of the OCF-18 ($200), leaving $1,100. This $1,100 would in fact be further reduced by ongoing costs such as medications. It is quite obvious how quickly the dollars for rehabilitation dwindle.
If a claimant with an initial diagnosis of a predominantly minor injury requires further treatment because a pre-existing condition, ongoing symptoms or other diagnostic findings — for example, a fracture, new neurological symptoms, depression, anxiety, panic attacks or Post-Traumatic Stress Disorder — present a barrier to maximal recovery within the $3,500, a claimant’s treatment would still fall within the $3,500 cap unless the health care provider gives compelling evidence that these are barriers to rehab.

There is no current definition of “predominantly” or “compelling evidence,” so an adjuster can determine if there is a predominantly minor injury and if evidence to take him/her out of the MIG is compelling or not. 

It seems adjusters are frequently denying OCF-18s despite compelling evidence that physical and/or psychological barriers are preventing maximum recovery. Adjusters seem to be making medical judgments irrespective of the medical evidence before them. This of course raises many ethical and legal issues the scope of which could not be done justice within the confines of this article.

On occasion, the adjuster may have an Insurer’s Examination (IE) done to clarify diagnoses. However, this does not necessarily mean that if the IE supports the need for additional treatment for a physical and/or mental condition, the OCF-18 will therefore be approved. If it is not approved, the claimant’s only recourse is mediation — usually a six-month wait.

Assessments

Under the new SABS, all assessments/ examinations, and related reports and expenses — including travel — are capped at $2,000, including those for catastrophic determination.

The only items not included in this cap are transportation expenses for the claimant and attendant and translation expenses.

In some cases, adjusters are including the $200 cap for the OCF-18, the new integrated request for assessment and treatment plan, as part of the $2,000 cap. Doing this allows only $1,800 for the assessment and all its related expenses. 

In a couple of cases, adjusters did not want to pay the $200 for the OCF-18, telling the service provider it should not have taken the provider more than one hour to do the preliminary screening and complete the form (even though it did). As a result, the adjuster was only willing to pay the provider’s professional hourly rate.  This is another example of adjusters making medical judgments.

The travel issue is especially critical for professions providing assessment and/or treatment services in the claimant’s home, school, job site or other community location. It appears in some instances, service providers have been asked to do specific assessments because of their expertise, but they were not able to take the referrals due to the cost of travel (e.g. flight, train, gas) and travel time. This limited access to services the claimant required.

For example, a occupational therapist was asked to travel up north to perform an attendant care assessment on a claimant deemed to have suffered a catastrophic injury. Airfare was $900. The trip door-to-door would take approximately 12 hours. On top of this, the therapist received this referral from a rehab company which of course had to earn its share of the cost. The therapist refused the referral. 

Are claimants in remote/rural areas therefore now being denied access to health care?

The general sense seems to be providers are being asked to “water down” their assessments and treatment services. Some providers are finding creative ways of addressing the needs of claimants and their respective College’s requirements for minimum standard of practice while trying to work within the new system. For example, providers might take a close look at their assessments and take out components that could be addressed in a separate, future assessment, or perhaps be performed more appropriately by another professional at a lower cost (such as “testing.”). In other cases, initial assessments are becoming a “screening” tool rather than full assessments. 

Some providers are contacting claimants and their legal representatives to request coverage of the additional cost beyond the $2,000 cap. If they agree, full assessments are done and the cost is covered under the tort side of the claim. If not, the referral is potentially refused or only a partial assessment or screening is done. In response to this assessment dilemma, some but not all rehab associations have produced guidelines for assessments or screening to assist their members.

Some say the $2,000 cap appears to be limiting or delaying access to the more complex assessments and subsequent specialized treatment performed by various professional groups. This observation is alarming because claimants requiring these types of assessments often have serious and usually multiple injuries.

Also of great concern is the anecdotal evidence of under-qualified providers agreeing to do some of these types of assessments within the $2,000 cap. One particular professional group has gone as far as to recommend to its members that if thes
e providers are professional peers, they are to be reported to their College for review of competency. All rehab professional groups know to do this according to their standard of practice.

Overall, in the area of assessments, the potential impact of the reforms might be threefold: 1) an increase in number of assessments by different providers that might have been done by just one provider in the pre-reform era; 2) access to specific therapy might be delayed extensively because of this drawn-out process of assessment; and 3) valuable time and dollars are taken away from essential treatment because assessment components are being integrated into treatment sessions.