Recently we issued a letter to the Healthcare providers in our network, providing them with an important update about how insurance companies view patient rehabilitation needs, and how they assess what is “reasonable and necessary”.
A 3-part test was established in General Accident Assurance Co. of Canada v. Violi(FSCO Appeal P99-00047), and it asks the following:
1. Are the treatment goals, as identified, reasonable?
2. Are these goals being met to a reasonable degree?
3. Are the overall costs (not just financial, but also investment of time, etc.) of achieving these goals reasonable, taking into consideration both the degree of success and the availability of other treatment alternatives?
In order to minimize unnecessary delay and disputes over whether an OCF-18 form should be approved, care providers should set out their proposed treatment plans in terms that will satisfy the three elements of the Violi test above. This is true in all cases, but it is especially important when submitting on behalf of chronic pain clients or patients.
Click here for more details about how the above test was applied in previous cases, and suggestions for actions healthcare professionals can take to set patients up for the best possible outcome.We hope that you find this information helpful, and welcome any further questions it raises in general, or with respect to any specific patient with whom you work. Please feel free to contact us directly at any time to discuss.