Service Provider ExaminationsWhat You Need to Know

Presenter: Wendy Horrobin

Financial Services Commission of Ontario

Introduction and Key Messages

Financial sectors regulated by FSCO

Our mandate

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Financial Services Commission of Ontario

Resources 3 Managers

24 Senior Compliance Officers

Market Conduct Compliance Unit

Activities• Compliance Examinations

o Mortgage brokering compliance audits and sweeps

o Insurance, Pensions and support others (Licensing)

o Annual Statutory Examinations

o Develops the Auto insurance questionnaire and conducts consequential examinations

o Ad hoc examinations as required

o Service Provider Examinations

• Handle Inquiries (Complaints)

• Informal market intelligence gathering

• Support Life Insurance and mortgage broking Suitability Review

• Support work to review insurance solvency regulation

• Support Industry Reviews, i.e Credit Union Review

Value Proposition:

MCCU conducts risk-based field examinations, financial assessments and market conduct reviews of FSCO regulated financial sectors in order to ensure consumer protection and legislative compliance.

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Financial Services Commission of Ontario 4

Our Regulatory Role

FSCO’s Approach:

Engage stakeholdersEducate market participants to ensure

complianceEncourage industry-based solutionsEnforcement in cases of non-compliance

Financial Services Commission of Ontario

Purpose & Scope of Examinations

When Did Examinations Begin?FSCO began examinations of licenced Service Providers on December 1, 2014 (when the regulations came into effect)

What is the Purpose of the Exams?Purpose is to ensure licenced Service Providers are in compliance with the Insurance Act and its regulations

What is the Scope of the Exams?Scope is to ensure that licenced service providers have appropriate systems in place with respect to their operations and billing practices for Motor Vehicle Patients claiming Statutory Accident Benefits

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Financial Services Commission of Ontario

FSCO’s Approach to the Examinations

FSCO is focusing not only on Compliance but also using the exams as an Educational Tool to help service providers establish practices and procedures in their day to day operations that will facilitate compliance.

For Example:The Standards of Practice regulations state that Service Providers (SP’s) have a duty to verify the identity of the individual whom it performs services for. Therefore, when FSCO is on-site, there is an expectation that SP’s will ask for photo ID (drivers licence, health card etc.). If not, FSCO would recommend the service provider implement such a policy.

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Financial Services Commission of Ontario

Examination Details

Who Will be Coming on Site?FSCO’s Senior Compliance Officers (SCO’s) will be performing the on-site examinations. If your business is selected for examination the SCO will contact you to set up a suitable time.

How Long Does an Examination Take?Examinations take approximately 1 business day (approx. 8 hours). However, there is no need to “close shop” but FSCO recommends to keep your patient schedule light in order to respond to questions from the SCO.

Why was my Business Selected?FSCO is currently selecting business at random as well as using risk factors identified during the licencing process.

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Financial Services Commission of Ontario

Examination Details

How Can I Prepare for the Examination?If you are selected, you can prepare by readying the following materials:

Legal entity information such as articles of incorporation and master business licence (where applicable).

Information on staffing such as health discipline practiced, registration/certification numbers, start and end dates.

Financial statements for past two years (note: the purpose of reviewing financial statements is to verify the responses provided in your licence application)

Recent HCAI billing activities, for example, reports, statements, summaries. Policies and procedures regarding billing practices for MVA patients. Completed OCF forms 18 & 23, 21. (The SCO will review to ensure the forms are completed

in compliance with the regulations. Personal information will not be collected and need not be disclosed for the purposes of the review.)

Your Principal Representative or other staff member should also prepare to demonstrate how your business accesses and undertakes billing procedures through HCAI or Patient Management Software.

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Financial Services Commission of Ontario

A Word Regarding Confidentiality

FSCO’s on-site examinations of service providers are about ensuring compliance with billing and business practices only; there will be no gathering or recording of medical or personal information of patients or clinical notes. As with any regulatory examination, SCOs are bound by confidentiality rules.

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Financial Services Commission of Ontario

Summary of Findings So Far…

FSCO has identified several issues while performing on-site examinations, below are the top five findings:

SP’s not verifying the identity of the individual OCF Forms not signed by either RHP or patient No findings SP’s do not have written policies and procedures in regards to their billing practices No formal complaint process

** We track Incidental findings that help our understanding of the Auto Insurance Industry

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Questions