Access to Treatment and the Treatment Plan Process

Author(s): Leonard H. Kunka

September 1, 2002


The September 16 changes propose replacing the current “pay pending” treatment approach with an assessment and treatment guideline process. This process would apply to certain, “less serious” injuries and would not require prior insurer approval.

  1. The Committee which is to be assembled by the Superintendent of the Financial Services Commission of Ontario (FSCO) to develop a fee and treatment protocol (“the Guidelines”) must include input from Health Care Professionals.
  2. The Guidelines should not be clinical guidelines. The Guidelines should simply be an entry point into the system for uncomplicated injury by specifying treatment which can be provided without prior approval of the insurer.
  3. The Guidelines should specify a clear and cost-efficient mechanism for people to move from inside to outside the box, where the injuries would initially put them “inside the box”, but they do not respond to the “in the box” approved treatment.
  4. In creating the “Guidelines Process”, the Superintendent of FSCO should review and consider the “utilization guidelines” published by many of the Colleges who regulate Health Care Professionals.
  5. The proposed amendment for one comprehensive treatment plan in any 30 day period during the first 6 months following injury, is unworkable. Certain treatment which is immediately required may be delayed because of the need to wait for other treatment providers to be consulted in order to prepare a comprehensive treatment plan. In addition, while treatment is progressing, often further deficits/disabilities become apparent and further treatment plans need to be created to address these further injuries.
  6. The proposal that treatment plans which are not responded to by an insurer within 7 days are deemed to be “approved”, is welcomed.
  7. There is a conflict between proposal 1d and proposal 3 of the Proposed Regulation Changes (SABS). 1d suggests that disputes over assessments would go directly to mediation, whereas proposal 3 suggests they would go to a DAC. Sending such a dispute to a non-binding mediation or to a DAC will not resolve the dispute quickly and will only serve to possibly delay treatment to the victim.
  8. The overall consensus was that for injuries which fall “outside of the box”, treatment providers should be entitled to conduct assessments as necessary, without the need to obtain prior approval from the insurer for the assessment. Alternatively, the amendments should provide for a simple process of direct approval between the treatment provider and the insurer. Should this procedure not resolve the issue, a quick and simple resolution process for disputes involving assessments is necessary.

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