Kaplan-HSP Examinations 101

Service Provider Examinations
What You Need to Know
Presenter: Wendy Horrobin
Introduction and Key Messages
 Financial sectors regulated by FSCO
Our mandate
Financial Services Commission of Ontario
Market Conduct Compliance Unit
• 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
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.
• Handle Inquiries (Complaints)
• Informal market intelligence gathering
• Support Life Insurance and mortgage broking Suitability
• Support work to review insurance solvency regulation
• Support Industry Reviews, i.e Credit Union Review
 3 Managers
 24 Senior Compliance Officers
Financial Services Commission of Ontario
Our Regulatory Role
FSCO’s Approach:
Engage stakeholders
 Educate market participants to ensure
 Encourage industry-based solutions
 Enforcement 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
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
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.
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.
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
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.
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
Financial Services Commission of Ontario
Financial Services Commission of Ontario
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