4. As part of her practice as a registered physiotherapist, the Respondent is regularly retained by medical assessment companies and insurers as an independent third party assessor to perform examinations to assist in determining the reasonableness and necessity of continued coverage for physiotherapy treatment.
5. In performing her assessments, the Respondent reviews the medical records provided to her by the insurer and may conduct an examination, which includes taking a history, and performing a physical examination and testing of the subject. In other cases, the Respondent bases her assessment solely on a paper review of the subject’s medical file. The nature of the assessment and the content of the medical record reviewed by the Respondent are determined by the insurer.
6. The Applicant was referred to the Respondent for six independent assessments. The Respondent provided in-person, physical examinations of the Applicant on four occasions and conducted two assessments based on a paper review of the Applicant’s medical records.
7. The Respondent’s assessments of the Applicant done on December 7, 2010 and May 17, 2012 each concluded that the proposed treatment plans were entirely reasonable and necessary. The assessments done on March 24, 2011 and July 14, 2011 concluded that the proposed treatment plans were partially reasonable and necessary. The paper review assessments done on August 29, 2011 and March 12, 2012 concluded that the proposed treatment plans were not reasonably necessary.
The Complaint and the Response
8. The Applicant complained:
• The Respondent repeatedly made negative comments about the Applicant’s treating physiotherapist. The Respondent stated that his physiotherapist’s “lack of information provided in reports is hurting [the Applicant] and [resulting in him] having to go through IME after IME”;
• The Respondent submitted reports that were “riddled with mistakes” and she quoted him making statements that are “completely ludicrous”;
• He believes that the Respondent’s “opinion seems to be favouring [his] insurance company’s bottom line”;
• The Respondent failed to amend her report dated March 13, 2012 after additional documentation was provided to her; and
• At his assessment on July 14, 2011, the Respondent “suggested to [him] that it might be in the best interest for [her] to call [his treating physiotherapist] directly” for clarification of an OCF-18 form; however, the Respondent failed to follow up with the treating physiotherapist.
9. The Respondent responded to the areas of concern raised by the Applicant as follows:
• She advised the Applicant that some of the treatment plans submitted by his treating physiotherapist lacked an explanation as to why the proposed treatment was reasonable and necessary, and that this resulted in the Applicant having to undergo repeated assessments. She meant no disrespect to the Applicant’s treating physiotherapist and, in fact, complimented the progress the Applicant was making under his treating physiotherapist.
• The Respondent acknowledged that there were some minor inaccuracies in her reports but stated that she relied on information the insurer and the Applicant provided to her and noted that none of the inaccuracies was material to the conclusions in her assessment reports.
• The Respondent acknowledged that she does copy basic information from one report to another, citing that this is common practice, and thus avoids having to cover this prior ground each time.
• The Respondent stated that her reports were not biased in favour of the insurer and noted that her opinions were, for the most part, favourable to the Applicant.
• The Respondent stated that she was not aware of any further information being provided to her after the paper review of March 13, 2012 and noted that she was never asked by the insurer to complete an addendum report based on new information.
• The Respondent denied that she offered to contact the Applicant’s treating physiotherapist and stated that it was not her usual practice to do so during the assessment process. She suggested that the Applicant may have confused this point with her willingness to speak with treating medical professionals after her assessment and report were completed.
The Committee’s Investigation and Decision
10. The Committee investigated the complaint and decided to provide the Respondent advice about ensuring the accuracy of her reports and the need to ensure that her practice in this regard is appropriate and to take no further action.