Ontario health practitioners racing to the SABS $3,500 finish line: adjuster

Multiple submissions for medical and rehabilitation assessments and treatment under the Statutory Accident Benefits Schedule (SABS) are creating difficulty for adjusters in determining which submission gets priority in payment, said Laurie Walker, McLarens Canada’s director of Ontario auto accident benefits.
The new Minor Injury Guideline provides $2,200 for treatment blocks and payable fees without the need for prior insurer approval, with a $3,500 cap for medical and rehabilitation expenses.
The caps have created pressure for medical practitioners to submit their invoice to ensure their services are covered under the new caps, Walker told delegates of the Canadian Defence Lawyers’ Accident Benefits Conference in Toronto on April 8.
For example, if there are multiple assessments for a single insured, the assessors are under pressure to submit quickly in order to make sure their assessment is among those included under the $3,500 cap.
“We’re starting to see multiple submissions of the OCF-23 [Pre-approved Framework Treatment Confirmation Form],” she said. “I got five submissions for one file from five different clinics.
“So, who gets paid first? And are [all of the physicians and clinicians] speaking to one another? It’s basically become a race to the $3,500 finish line.”
A clause in Section 38 of the SABS is also creating a Catch-22 for those in the insurance industry, Walker continued.
The clause says expenses for medical or rehabilitation devices under $250 do not need to be included in the insured’s treatment plan.
“We are getting invoices and receipts for all sorts of devices that are all $249,” Walker said. “Now that the insured has included those expenses, they’re owed.
“It’s really a Catch 22, because those expenses don’t get submitted through HCAI. We have no idea if they’re coming in because of this little clause. So, we’re seeing some abuse in that area.”