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Communication, conflict concerns for independent health assessors

By Lonny Rosen & Elyse Sunshine

recent matter before the Health Professions Appeal and Review Board (the Board) exemplifies the importance of open communication and having clear reimbursement processes when patients are referred to independent health assessors by third party insurers. This decision is a reminder that independent assessors need to take steps to demonstrate impartiality and avoid conflicts of interest, in order to avoid complaints and to be in a position to respond when complaints arise.

The complaint

A woman was referred by her insurance company for a psychological assessment following a stress leave from work. She was collecting long-term disability benefits and had a very demanding personal situation (including looking after children with disabilities). She did not have the time to engage in a four-day assessment or intensive treatment for which she had been referred to the psychologist. When the woman met with the psychologist, she understood that the psychologist had agreed not to proceed with the assessment and that she was not going to schedule any follow-up appointments.

However, the client received a call from her insurance provider indicating that, while she would still receive her long-term disability benefits, the psychologist would be scheduling an assessment closer to her home so it would be easier on her. The psychologist, who changed her decision following consultation with colleagues, did not advise the client of this; the client only found out through the third party insurer.

The client complained about the psychologist’s conduct to the College of Psychologists of Ontario. She also expressed concerned that the psychologist engaged in a conflict of interest by maintaining a relationship with the client’s insurance company, using information from the client to secure business from the insurance company, and offering a “bribe” in the form of a reimbursement for expenses.

The Inquiries, Complaints and Reports Committee (ICRC) investigated and decided to advise the psychologist that when working with a client via a third party (such as an insurance company) it was advisable to inform the client as well as the third party about any changes in her process or opinion, including how and why the change was made. It was also advisable to make clear on any reimbursement form that the insurer was responsible for payment and explain clearly how the client may claim the funds. The issuance of advice is a very favourable outcome for a health professional who is the subject of a complaint, as the professional does not face discipline and, unlike in the case of a caution, there is no notation of the advice provided to the professional on the public register.

The complainant requested that the Board review the ICRC’s decision.

On review, the Board found that the ICRC’s investigation was adequate and its decision was reasonable, as the psychologist had sufficient information to change her opinion regarding the assessment. The Board noted, however, that it would have been helpful for her to have communicated it to the client rather than have the third party insurance company tell her. Also, the Board agreed that the reimbursement form that the psychologist gave to the client could have created the perception that the psychologist’s place of employment was paying the expense and not the insurer. However, that was not the case. The Board found that information on the form was lacking.

Takeaway

Due to the nature of independent assessments and the significance of the outcome of such assessments to clients, health professionals who act as independent assessors are at greater risk of complaints than those who simply provide treatment to clients. Any health professional who is acting as an independent assessor should take the proper steps (including through clear communication with the client themselves) to ensure impartiality and be aware of the potential for an appearance of conflict of interest.

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