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Presentation-Auto_Insurance_Health_System___HCAI

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					Auto Insurance & Clinical Practice: Bridging the Gap

Viivi Riis BScPT, MSc: HCAI Senior Health Analyst Allison Brand: HCAI Senior Business Analyst

Agenda
Why HCAI The auto insurance system instruction manual OCF forms 101 (what are insurers looking for) Who can sign OCF forms HCAI demo Injury and treatment coding Q& A

The 1993-2002 Story
Cars are being hurt less
20% more (and safer) cars on the road up 43% lower rate of damage claims for cars in collisions

People are being hurt more
30% more injury claims overall 95% higher rate of injury claims

Injury claims affecting cost of insurance
Cost of average injury claim is up >60% Cost of insuring a car is up >35%

So, what is HCAI?
Health Claims for Auto Insurance (HCAI)
Online submission, review and approval of key auto insurance claims forms

What is HCAI?
Health providers will submit:
(OCF-18) Treatment Plan * (OCF-22) Application for Approval of an Assessment or Examination * (OCF-23) Pre-approved Framework Treatment Confirmation Form (OCF-21 A,B & C) Standard Invoice

* when not waived by insurer

Insurers will provide:
Key claim/claimant data Approval and payment decisions

Why HCAI?
Property & Casualty Insurance
Single largest private payer of outpatient medrehab services

System is “benefits-based”
Insurer is engaged in health payment decisions Insurers are not engaged in health treatment decisions If an insurer declines payment of an expense, it does not prevent the HP from delivering the treatment – but funding must come from elsewhere

Do we know if the auto insurance health system is working?
NO – we suffer a HUGE data deficiency
Injury claims costs escalating Little is known about expenditures incurred in the motor vehicle collision (MVC) sector Clinical research continues but does not address auto insurance framework specifically
• What care is being delivered, by whom, under what conditions, at what cost and with what outcomes

Decision-making by policy makers, regulators, insurers and health providers being carried out in a vacuum

Where’s the User Manual for Auto Insurance?
E-laws Ontario The SABS is a regulation under the Insurance Act
http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_960403_e.htm

AB versus BI Claims
AB Claim (standard benefits)
Non catastrophic
•Medrehab $100 k •AC $72 K •IRB $400/wk for 1st 104 wk $185/wk after 104 wk

BI Claim
•$30 k deductible •Recovery of health expenses not covered by AB •Recovery for pain and suffering

Catastrophic

•Medrehab $1,000 k •AC $1,000 K •IRB $400/wk for 1st 104 wk $185/wk after 104 wk

Different Kinds of Benefits
A “benefit” is something that the insurer must pay for IF it meets the eligibility test Benefits in Ontario
Income Replacement Benefit Medical Benefit Rehabilitation Benefit Attendant Care Benefit Homemaking and Home Maintenance Benefit

Medical Benefits
What are the criteria that must be met for an insurer to pay a medical (e.g. to overcome impairment) benefit? Section 14
Impairment as a result of an accident Reasonable Necessary Not experimental

Rehabilitation Benefits
What are the criteria that must be met for an insurer to pay for a rehabilitation benefit? Section 15
Must reduce or eliminate the effects of any disability resulting from the impairment or to facilitate the insured person’s reintegration into his/her family, the rest of society and the labour market.

Income Replacement Benefit
What criteria must be met for an insurer to pay for an income replacement benefit? Section 4
Impairment as a result of an accident Substantial inability to perform essential tasks of employment. Not payable after 12 wk (WAD I) or 16 wk (WAD II) Not payable after 104 weeks unless
• Complete inability to engage in employment for which he/she is reasonably suited by education, training or experience.

What Are Automobile Insurers Looking For?

Allison Brand Senior Business Analyst HCAI Processing

OCF Forms & Signatures
The Dependent Provider Terms and Conditions Form and the Affiliated Provider Terms and Conditions Form must be signed by each health provider that is “associated” with a given health facility The signature of the health provider simply acknowledges that they are indeed associated with that health facility and that they will abide by the HCAI Terms and Conditions

OCF Forms & Signatures

The signature of a health provider on HCAI Terms and Conditions forms does NOT permit the health facility (clinic/practice/business) to use the providers signature on OCF forms at any time All OCF signatures must be obtained through a process whereby the signing health provider puts a pen to paper for each and every OCF form that they agree to sign

OCF 18 Signatures

Part 5 - Health practitioner to certify the OCF 18 is reasonable and necessary
Refer to the SABS to determine who is qualified to sign as a health practitioner

OCF 18 Signatures
Part 6 - Health professional (if applicable) to supervise the treatment plan
If the signer of Part 5 is associated with the health facility, he/she may also assume responsibility for Part 6 (supervision of the treatment plan) If the signer of Part 5 is external to the health facility (i.e not associated as a provider), then a regulated health professional that IS associated with the clinic MUST sign Part 6

OCF 18 Signatures

Part 14 - Claimant (patient) unless the claimant signature is waived by the insurer

OCF 22

Part 3 – Regulated health professional or social worker to certify the services proposed are reasonable for the assessment or examination of the applicant Refer to the SABS to determine who is qualified to sign as a health professional or social worker Optional – Part 9 signature of claimant If signature not obtained, provider is responsible for ensuring claimant consent is provided

OCF 23
Part 5 - Health practitioner to certify the OCF 23 is reasonable and necessary
Refer to the SABS to determine who is qualified to sign as a health practitioner Part 13 - Claimant (patient) unless the claimant signature is waived by the insurer

Injury & Intervention Coding for OCF Forms

Canadian Institute for Health Information (CIHI)

CIHI is an independent, not-for-profit organization providing essential data and analysis on Canada’s health system and the health of Canadians
Data pertains to publicly funded health system

Canadian Institute for Health Information (CIHI)
CIHI Mandate
To serve as a national coordination mechanism for health information in Canada To set national standards for health data classification, collection and utilization To provide accurate and timely information that is required for:
• Sound health policy • Effective management of health care system • Public awareness of health determinants

HCAI
HCAI will collect standardized data and will build data repositories that will provide information about the Ontario auto insurance health system To serve as a provincial coordination mechanism for health information in Ontario’s auto insurance system To provide accurate and timely information that is required for:
Sound policy Effective management of the auto insurance health care system Stakeholder and public awareness of health issues in the system

Coding Challenges
Training
Formal training in coding procedures and protocols have not been provided to health providers or insurers Insurers may have expectations with respect to coding; but
• Health providers may not know what those expectations are

Needed
A common understanding of how injury and intervention coding is intended to be used by health providers and interpreted by insurers

Overview of Classifications
ICF - International Classification of Functioning, Disability and Health ICD-10-CA - International Statistical Classification of Diseases and Related Health Problems (10th revision, Canada) CCI - Canadian Classification of Health Interventions

Overview of ICF
International Classification of Functioning, Disability & Health Key features:
body functions and structures activities and participation, and environmental factors domains classified from body, individual and societal perspectives.

ICF
International Classification of Functioning, Disability and Health
Health Condition (disorder/disease)

Body function&structure (Impairment)

Activities (Limitation)

Participation (Restriction)

Environmental Factors

Personal Factors

Tell the Patient’s Story

Injury/problem coding captures information to paint a picture of the injured person Main Problem Other Problem(s)

Main Problem (MP)

The Main Problem is the problem that
Is deemed to be the clinically significant reason for the client’s visit to a health professional; and Which requires evaluation and/or treatment or management

This can be a diagnosis, condition, problem or circumstance

Main Problem (MP)
Who decides?
Assigned by the health care provider at the end of the visit. This may be the physician or another health care professional responsible for the client’s care (e.g. Allied Health Professional) ICD-10-CA are NOT profession specific

Main Problem - Injuries Caused by Auto Collisions
Outcomes of physical injuries sustained in an MVA
S&T Codes (usually)

Subsequent manifestations of those conditions
F&Z Codes

Examples
S13.41 Whiplash associated disorder F32.0 Mild Depressive Episode (e.g. secondary to injuries caused in a collision) Z59.1 Problems related to inadequate housing (e.g. altered housing needs due to spinal cord injury caused by collision)

Other Problem (OP)
What
Problems, conditions or circumstances, related to the automobile collision, which coexist at the time of the client’s visit and which influence the client’s need for treatment or care Previous conditions that no longer exist (like a healed fracture) that may affect the response to treatment

Would also be recorded in the health provider’s chart

Case 1
Insurer requests S42 assessment from OT
Claimant with SCI Home is not WC accessible Need to determine how to make home independently accessible for claimant

Main problem responsible for service delivery of OT
Difficulty/inability to access home and rooms in home

Problem code
Z588 - Other problems related to physical environment

Case 2
Mary Jones broke her L femur in a crash 3 weeks ago
She sees a PT after her cast is removed (about 6 weeks after the collision) Note - fracture has healed (in other words, the main problem being addressed by the PT is NOT the fracture)

Main problems responsible for PT services
M25.66 – Stiffness of joint, not elsewhere classified, lower leg M79.61 – Pain in lower limb

Other problem
S72.9 - #’d femur (original injury)

Case 2
Mary Jones broke her L femur in a crash 3 weeks ago
8 weeks after the collision, she also sees a psychologist since she is experiencing fear and anxiety which limits her ability to drive Psychologist assesses patient

Main problems responsible for psych services
F40.2 – Specific (isolated), phobias

Other problem
M79.61 – Pain in lower limb S72.9 - #’d femur (original injury)

Case 3
Main problem Insurer requests S42 assessment for claimant with SCI to determine how to make home independently accessible for claimant.
Difficulty/inability to access home and rooms in home. Z588 - Other problems related to physical environment

Other problem
S1410 - complete lesion of cervical spinal cord G82.5 - tetraplegia

Injury Coding and Multiple Providers
Multiple Providers
When multiple problems deliver care, the Main Problem is that which is responsible for the greatest use of resources Other problems (subsequent lines) are reflected in subsequent lines

Injury Coding and Multiple Providers
Example: SLP and OT services to be delivered to pt with ABI
OT services - improve independent functioning daily Rx for 2 hours SLP services – improve swallowing - twice per week for an hour each session

Main problems
T90.05 (sequelae of intracranial injury) Z50.7 (OT not elsewhere classified) R47 (dysphasia)

Other Problems
S06.2 (diffuse brain injury)

Case 4
John Doe undergoes a S 42 assessment
The assessors (orthopedic surgeon and psychologist) determine there is no ongoing physical or psychological impairment The code should represent the reason an assessment was required (assuming patients with no complaints would not undergo assessment)

Main problem
Note - insurer requested assessment in response to a treatment plan submitted that reported pt continues to report pain of leg Codes should represent problem responsible for services delivered

M79.6 “Pain in limb”

Case 5
Patient sustained fractured femur which has healed, but stiffness and pain continue.
PT treating for stiffness and pain Patient reports that employer is not happy about pt having to leave work for PT treatment in middle of day

Main problem
M25.66
• Stiffness of joint, not elsewhere classified, lower leg

M79.61
• Pain in lower limb

Other problem
• Z563 - Stressful work schedule • S72.9 - Fracture of femur, closed (original injury)

Conditions That No Longer Exist

Conditions previously treated and which no longer exist are collected as Other Problem(s)
Coded in rows below the Main Problem

Bilateral Injuries
Left and right are not specified If bilateral injuries, do not use duplicate codes
Instead, use T series “Injury,….and other consequence of external causes (multiple)” Example: bilateral femoral fractures
• T025 - fractures involving multiple regions of both lower limbs

Overview of CCI
Canadian Classification of Health Interventions Key features:
Service Provider & service setting neutral Comprehensive, dynamic & expandable Relevant Developed by CIHI

CCI Rubric – Describe “What”

What Treatment or health intervention is being used to manage the problem(s) caused by the automobile collision

10

CCI Rubric –“What”
Section
Broad realm of intervention E.g.. therapeutic, diagnostic, cognitive

Group
Region or area of focus E.g.. Anatomy site

Intervention
Generic types of healthcare actions
1.SG.09 Stimulation, muscles of the back (covers off TENS, US, IFC, Laser) 6.VA.50 Training, Motor Functions 7.SC.01Assistance, Personal Care

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