(Be sure to reset your autopilot…)
The pun is intentional, even if the parallels are accidental.
The first MIG aircraft, the Model 1, was a low-wing monoplane of mixed construction with a taildragging undercarriage. It underwent a number of improvements before the last one was retired in 1944.
Sixty-six years later we have the Minor Injury Guideline with its $3,500 benefit maximum for non-catastrophic injuries – compared to the current limit of $100,000. Its introduction is anticlimactic, as it follows a protracted review that seemed to drag on without end, and it is receiving mixed reviews. As in the world of aeronautical design and construction, it is also a safe bet – indeed it is the stated intention – that someday this MIG will be superseded by the next best thing in the regulation and administration of auto injury benefits.
The MIG first saw the light of day as Section 40 of Auto Insurance Regulation 34/10 published in February of this year. In June further details were presented as Superintendent’s Guideline No. 02/10. Regulation 34/10 is one of six that resulted from the year-long review of Part VI of Ontario’s Insurance Act (see the articles Ontario Auto Insurance Reforms and Understanding Practice Risk in the Spring issue of The Health Professional) and will be in effect for accidents occurring September 1, 2010 and later.
FSCO states the objectives of the MIG as:
- Speeding access to rehabilitation for minor MVA injuries
- Improving the utilization of health care resources
- Providing certainty around costs and payments for insurers and regulated health professionals
- Providing immediate access to treatment without insurer approval for minor injury assessments and treatments
Within the $3,500 maximum, there is a pre-approved limit of $2,200 for assessments, treatments, supplementary goods and services (maximum $400) and discharge reporting, and is supposed to follow a prescribed service blocking and sequencing model. The pre-approval applies provided an eligible health practitioner prepares and signs the treatment confirmation using the new version of the OCF-23 form.
The MIG was controversial before it even got off the ground. The Health Professional does not intend to wade into the fairness or adequacy debates. However, this article will comment on the MIG’s many implications for patients and practitioners and it will outline how, in a MIG world, practitioners can still navigate care pathways in a way that lessens the probability of assessment and treatment disruptions for patients.
As the character who plays Robert McNamara in the movie 13 Days exclaimed to his trigger-happy, bow-shot-firing Navy counterpart, his precipitous act was “language” whose expression must be carefully considered to avoid misunderstanding of intent.
The MIG is powerful language indeed, and it leaves no doubt that the regulator continues to include within its purview and prerogative the dissemination of what it views as optimal clinical practice for the management of injuries covered under the SABS. Witness the Pre-Approved Framework Guidelines Project of 2007 during which FSCO commissioned at least one background paper and consulted widely with insurers and health professionals to gain a better understanding of best intervention, assessment and treatment practices for WAD I and II injuries.
The MIG sets additional precedents that cannot be ignored, and providers and insurers might justifiably interpret its language as intent to get into their respective backyards. Readers are strongly encouraged to read the Guideline.
In some important respects, the MIG is an extension of the PAF model beyond WAD I and II injuries. The regulation states that a minor injury means a sprain, strain, whiplash-associated disorder, contusion, abrasion, laceration or subluxation, and any clinically associated sequelae. The term “minor injury” is intended to apply to one or more of the following injuries.
Sprain: An injury to one or more tendons or ligaments or to one or more of each, including a partial but not a complete tear
Strain: An injury to one or more muscles, including a partial but not a complete tear
Subluxation: A partial dislocation of a joint
Whiplash injury or whiplash-associated disorder: Acceleration-deceleration injury to the neck that does not exhibit objective, demonstrable, definable and clinically relevant neurological signs and is not accompanied by spinal fracture or dislocation
The MIG, then, applies to the large majority of MVA injuries, possibly as many as 80%. The regulation further states that the OCF-18 (treatment and assessment plan form) can continue to be used to apply for benefits under the new $50,000 limit for serious injuries, but it sets out a major proviso, quoted verbatim below to ensure that readers understand its definitive language.
“Only in extremely limited instances where compelling evidence provided by a health practitioner satisfactorily demonstrates that a pre-existing condition will prevent a person from achieving maximal recovery from the minor injury for the reasons described above is the person’s impairment to be determined not to come within this Guideline. Exclusion of a person from this Guideline based on reasons or evidence falling short of this requirement is inconsistent with the intent of the SABS and this Guideline.”
What the MIG Means for Providers
Providers who were adept at navigating the regulations in the pre-MIG era in a way that brought them high adjuster approval rates and maximized fee revenue now have to reset their autopilots. Indeed, if they want to avoid in-flight adverse events and hard landings, they would be wise to assume that nothing will be automatic and to revert to what pilots refer to as visual flight rules in the best interests of their patients and the health of their practices.
Some insurers may not have the tools required to effectively administer decision rules for what constitutes a serious injury and the $50,000 limit that applies to such injurues. By the same token, in the absence of sophisticated internal claim adjudication rules and controls, some may well take the position that except for injures that are obviously catastrophic in nature, the Insurer Exam mechanism should be the final arbiter whenever an OCF-18 is submitted.
Differing definitions of “serious” are bound to complicate the assessment/treatment flow, and will likely expose some clinical practices to financial risk if services are performed for which payment is ultimately denied by insurers or their independent adjusters. Providers would be well advised to update their referral intake procedures to determine whether or not their patients have optional auto benefits coverage.
Providers who strongly believe that patients’ injuries fall outside the MIG and who can support their contention with credible evidence should also consult with patients’ auto claims adjusters to obtain pre-approval. Given the importance of patient service and assessment/treatment continuity, pending their negotiations with insurers they should also ensure that their patients fully understand what their payment obligations are for denied claims.
The SABS could be viewed as a public/private trust whose disbursements are for the benefit of claimants. Its moral, if not legal, fiduciaries are insurers, providers and Ontario’s financial services regulator. If standardization, consistency and equity are among the MIG’s stated and implied objectives, there is still work to do to ensure that, for claimants whose injuries fit the same profile, a consistent level of financial support is provided in practice as well as in theory.
Furthermore, though laudable, the $400 allowance for supplementary services and supplies included in the $2,200 pre-approved limit could be manipulated to cover additional (i.e. high margin) services instead of the supplies needed to promote the self-rehabilitation and functional restoration aims of the Guideline. Gross profit-taking on devices and supplies to the detriment of claimants also remains an issue, and one that could and should be controlled.
Change is at hand; the MIG is airborne. All stakeholders have a role to play to ensure that its course leads to its desired destinations. THP
The SABS could be viewed as a public/private trust whose disbursements are for the benefit of claimants. Its moral, if not legal, fiduciaries are insurers, providers and Ontario’s financial services regulator. If standardization, consistency and equity are among the MIG’s stated and implied objectives, there is still work to do to ensure that, for claimants whose injuries fit the same profile, a consistent level of financial support is provided in practice as well as in theory.
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