Health Service Provider (HSP) licensing toolkit, understanding your FSRA licensing obligations | Financial Services Regulatory Authority of Ontario
The purpose of this document is to provide existing and new Health Service Providers (“HSPs”) with information on the duties, responsibilities, and regulatory compliance requirements expected of a licensed HSP.
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fsra regulates the billing practices of fsra authorized service providers to help maintain fair and reasonable auto insurance rates for consumers. Health service providers are typically physicians, health and rehabilitation clinics, and screening and testing providers. HSPs serving patients receiving accident benefits due to automobile insurance claims must be aware of the contractual obligations between the claimant and their insurer.
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fsra objects in the health service provider sector:
regulate and oversee health care providers to ensure financial security and equity for Ontarians.
participate in dynamic regulation based on principles and focused on results by monitoring and evaluating developments and trends.
promote honesty and credibility in the industry by deterring deceptive or fraudulent conduct, practices and activities.
fsra will regulate health care provider business systems and billing practices as described in the rules for regulating business systems and practices in ontario regulation 90/14 and section 288.4 of the insurance act .
Disputes relating to an insured person’s entitlement to statutory accident benefits or the amount of statutory accident benefits an insured person is entitled to are sole jurisdiction of the court of appeals of licenses. visit the following website for more information: https://tribunalsontario.ca/lat/automobile-accident-benefits-service/
Should my business apply for a fsra healthcare provider license?
Companies that wish to bill auto insurers through hcai and be paid directly by auto insurers for specified listed expenses1 will need a license.
A health care provider license will authorize the business to receive direct payments from auto insurers for the specific expenses listed.
Unlicensed health care providers are still required to submit all Ontario Claim Forms (OCF) through the HCAI system. however, they will not be able to receive direct payment from auto insurers. insurance companies will pay directly to claimants who receive treatment from unlicensed health care providers. claimants will have to reimburse the clinic for services rendered.
the primary representative (pr) is the person designated by the health care provider to be the primary contact with fsra. the pr will be primarily responsible for the health service provider’s license and compliance with the law.
the pr has the authority to make decisions on behalf of the licensee. The PR is responsible for communicating with FSRA regarding matters related to the license and the licensee’s compliance with the Insurance Act (Ontario), as outlined in Ontario Regulation 349/13.
these are duties of the main representative:
File the annual information return and pay the annual regulatory fee by March 31 of each year (unless otherwise directed by fsra).
ensure that the licensee and any person authorized to provide specified goods or services on behalf of the licensee comply with insurance law.
ensuring that the licensee’s business systems, practices, and oversight of licensee operations comply with the law and are conducted with integrity and honesty.
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make recommendations to the licensee regarding changes in its business systems, practices and oversight of its operations, as necessary.
take reasonable steps to implement a monitoring system that ensures that all requirements established by law are met.
provide certifications on behalf of the licensee about the licensee and about the licensee’s compliance with the law, as required by the executive director.
Having a health care provider license with fsra means that health care providers may be subject to on-site examination by fsra at some point. fsra’s processes for licensee review will emphasize a risk-based approach. This risk-based approach uses complaint data, licensing information, airs, health claims database data, and sanctioned physician information.
An important part of maintaining a health care provider license is meeting the standards for business systems and practices described in o. record 90/14. In accordance with these requirements, among other things, all licensees must:
file an annual information return (“air”) and pay the annual regulatory fee (“arf”) by March 31 of each year, unless otherwise directed by fsra.
report changes in the health care provider’s business to fsra within five (5) business days. these changes include changes in contact information, principal representative, directors, officers or partners.
respond to carrier requests within ten (10) business days for certain types of information. This information includes the health care provider’s fsra license number and specific details about the people who have been authorized to provide goods or services on their behalf.
do not send bills or other documents to hcai if the health service provider suspects the presence of inaccurate, false or misleading information.
retain any records related to the goods and services provided by or on behalf of the health care provider related to the listed expenses for at least six (6) years from the date the record was created. Records may be maintained in electronic or paper format, but must be retrievable within five (5) business days of receipt of a request.
A licensed health care provider shall establish and implement appropriate policies and procedures considering the nature and volume of the health care provider’s business related to statutory accident benefits.
Health professionals must comply with the professional standards and code of conduct of their respective associations.
Make sure each facility, branch, or location is registered with Health Claims for Auto Insurance (HCAI).
comply with the requirements of the hcai superintendent’s guideline.
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maintain an updated list in the hcai system of those health professionals who provide services for the establishment. This is commonly known as the HCAI “list”. When a healthcare professional stops providing services for the business, the facility is required to update their HCAI account with an “end date” for that provider. this ensures that no more treatment forms or bills will be submitted with the credentials of the previous provider.
Use approved OCF forms only, if the CEO has approved a form under the Statutory Accident Benefits Program (SABS).
Perform periodic reviews of documents submitted to insurers (as described in the regulation) to ensure compliance with applicable laws and guidelines, and reconciliation of invoices.
treatment plans (ocf-232 & ocf-183) must be signed by both sabs applicants and practitioners.
verify patient identification data for each claimant. health service providers must have procedures to verify the identification of the claimant and be able to demonstrate that the process was followed.
invoices (ocf-214) must be signed by an authorized person. the authorization process must be well documented and acknowledged by the authorized person.
A licensed service provider shall not submit a bill for an indicated expense to an insurer using a name or license number other than the name and license number corresponding to the service provider’s license.
one-time license fee
This one-time license fee covers the cost of evaluating the application for compliance with regulatory requirements and determining if the applicant qualifies for a license.
annual regulatory fee (arf):
This annual regulatory fee covers the cost of regulating the health service provider sector. the statutory fee is proportional and varies depending on the size and nature of the applicant’s business.
The annual regulatory fee is calculated according to the following formula:
a + b
“a” = $128 x the “number of locations”5
“b” = $15 x the “number of sabs claimants”6
Note: If your regulatory fee is $5,000 or more, please send a check, money order, or money order (with money order attached) made payable to “fsra” or “fsra” financial services”. of Ontario” to the following address:
25 sheppard avenue west, suite 100, toronto, on, m2n 6s6
For a list of frequently asked questions, see the following website: https://www.fsco.gov.on.ca/en/service-providers/faqs/pages/default.aspx