On October 30, 2020, the Lieutenant Governor in Council made amendments to three pieces of automobile insurance-related legislation that affect Alberta physiotherapists’ practice. The Diagnostic and Treatment Protocols Amendment Regulation, the Minor Injury Amendment Regulation and the Automobile Accident Insurance Benefits Amendment Regulation came into effect on November 1, 2020.
These amendments are separate and distinct from the Report on Fundamental Reform of the Alberta Automobile Insurance Compensation System which was presented by the Automobile Insurance Advisory Committee to the Minister of Finance in September 2020 and which is currently being reviewed by government.
The College of Physiotherapists of Alberta has now had the opportunity to review the amendments and the recent bulletin issued by the Superintendent of Insurance’s Office highlighting key changes to the Regulations. We have also had the opportunity to discuss the amendments and their interpretation with representatives from the Superintendent’s Office.
The College of Physiotherapists of Alberta wishes to advise regulated members of key changes that will affect their practice if they work with individuals who have been injured in a motor vehicle collision.
Changes to the Diagnostic and Treatment Protocols Regulation:
- Addition of $1,000 for adjunct therapies provided by dentists, psychologists and occupational therapists.
In the past, adjunct therapies provided by regulated members of these professions were accessed from the 10 or 21 visits allocated in the DTPR dependent on the severity of the patient’s injury. With the addition of these dedicated funds, services provided by dentists, psychologists and occupational therapists will be funded separately from physiotherapy and chiropractic services available under the DTPR and will not impact on the number of DTPR treatment visits available.
- The addition of subsection 1(3), which reads:
(3) For the purpose of this Regulation, an in-person visit to a health care practitioner or another person authorized to provide treatment under this Regulation constitutes a single visit, irrespective of the number of injuries treated during the visit. [emphasis added]
Two aspects of subsection 1(3) are of note. Firstly, the use of the term in-person has been clarified by the Superintendent of Insurance to include both in-person and telerehabilitation services provided by physiotherapists.
The wording of the latter part of this subsection, that a “visit to a health care practitioner… constitutes a single visit, irrespective of the number of injuries treated during the visit,” has led to many questions to both the Superintendent’s Office and the College of Physiotherapists of Alberta.
The Superintendent’s Office has advised the College of Physiotherapists of Alberta that the wording was added due to frequent concerns and complaints from patients and other parties. The issue arises due to the past practice of some physiotherapists who treated two DTPR injuries and charged for two treatment visits as part of a single patient attendance at the practice setting, without the patient understanding and consenting to the physiotherapist’s actions and the effects on the number of attendances the patient would access.
Physiotherapists know that it is not uncommon for patients to sustain more than one distinct injury (e.g., a C-spine WAD injury and a sprained ankle) from a motor-vehicle collision. Such distinct injuries warrant a fulsome assessment and individualized treatment to achieve functional recovery. This requires dedicated time and attention to each injury. The Client-Centered Care Standard of Practice requires that the physiotherapist:
- Values the best interests of clients
- Involves clients in decision-making regarding their care, respecting their independence and right to refuse or withdraw from treatment at any time
- Communicates with clients to facilitate their understanding of the care plan and how it addresses their goals, outlines the risks and benefits of services, and obtains informed consent
Arguably, providing care for multiple injuries during one attendance at the practice setting demonstrates client-centered care as it respects the client’s time and individual needs and avoids inconveniencing the patient by requiring them to make multiple trips to the practice setting within the same week for treatment of different injuries.
This point was raised with the Superintendent’s Office, which clarified that the Superintendent has no interest in interfering in the appropriate clinical management of patients by physiotherapists. When two distinct injuries warrant time and attention from the treating clinician, the clinician may provide and claim for two treatment visits on the same day. The intent of the addition of this subsection is to control for situations where two treatment visits are claimed on the same day, without the client being aware of the implications, and consenting to the practice.
The College of Physiotherapists of Alberta recognizes that this clarification differs from the express language of the Regulation; however, the Superintendent’s clarification is consistent with the long-standing expectations of the College of Physiotherapists of Alberta. Physiotherapists who are providing treatment to two distinct injuries under the DTPR have always been expected to:
- Allocate a treatment “slot” or booking time for each injury treated
- Ensure that documentation clearly demonstrates that two distinct injuries have been treated
- Ensure that the patient is aware of the implications of treating two injuries during a single attendance at the practice setting
These expectations relate directly to the Standards of Practice which require that the physiotherapist:
- Communicates effectively with clients to promote their understanding of proposed services (Communication Standard of Practice)
- Clearly communicates applicable fees to clients and payors prior to the provision of physiotherapy services. (Fees and Billing Standard of Practice)
- Provides clients with clear, transparent, accurate, and comprehensive invoices/receipts, in a timely manner. (Fees and Billing Standard of Practice)
- Communicates with clients to explain and facilitate their understanding of physiotherapy service options. (Consent Standard of Practice)
- Obtains and documents clients’ ongoing informed consent to proposed services. (Consent Standard of Practice)
Although physiotherapists may think of consent as being related to treatment interventions, in this case, the patient must also provide informed consent to receive treatment in this manner and understand that the implications of doing so include that they will:
- Be at the practice setting for an extended period for each single attendance to enable treatment of more than one injury.
- Ultimately attend the practice setting less than the number of visits allocated in the DTPR, due to the use of multiple treatment visits during a single attendance.
Changes to the Minor Injury Regulation:
The most significant change for physiotherapists relates to the definition of “minor injury”. As stated in the regulation:
(h) “minor injury”, in respect of an accident, means
(i) a sprain,
(ii) a strain, or
(iii) a WAD injury
caused by the accident that does not result in a serious impairment and includes, in respect of a sprain, strain or WAD injury that occurs on or after November 1, 2020, any clinically associated sequelae of the sprain, strain or WAD injury, whether physical or psychological in nature, caused by the accident that do not result in a serious impairment.
Although the Superintendent issued a notice on May 17, 2018 identifying that both physical and psychological injuries when caused by a motor vehicle collision and clinically associated with a sprain, strain or WAD were considered minor injuries under the Minor Injury Regulation, this amendment formalizes that interpretation in the Regulation.
The addition of psychological injuries within the definition has been confirmed to include injuries such as post-traumatic stress disorder and concussion when those injuries are caused by a collision, do not result in a serious impairment, and are clinically associated with a sprain, strain or WAD injury.
Physiotherapists are reminded that the Minor Injury Regulation establishes those injuries to which the cap on non-pecuniary losses (pain and suffering) applies.
The change in the Minor Injury definition does not mean that these injuries are now included within the DTPR, though physiotherapists familiar with the management of post-concussion syndrome will be aware that some post-concussion symptoms may relate and be amenable to treatment of the C-spine. In discussion with the Superintendent of Insurance’s Office, it was clarified that if post-concussion syndrome requires treatment distinct from the management of a sprain, strain or WAD injury (e.g., vestibular rehabilitation), the concussion treatment is reimbursed from Section B benefits.
If the post-concussion syndrome arising from a collision does not resolve in parallel with an associated sprain, strain or WAD injury, and results in persistent symptoms causing serious impairment, the concussion would not be considered a Minor Injury.
The definition of “serious impairment” provided in the Minor Injury Regulation is unchanged from previous.
Changes to the Automobile Accident Insurance Benefits Regulation
The AAIBR is the legislation that relates to Section B Accident Benefits - the $50,000 allocated for
“all reasonable expenses incurred within 2 years from the date of the accident for necessary… physical therapy… services and, in addition, for other services and supplies, including any medically necessary equipment, home modifications or vehicle modifications, that are, in the opinion of the insured person’s attending physician and in the opinion of the Insurer’s medical advisor, essential for the treatment or rehabilitation of the injured person.” [emphasis added]
The recent amendments to the AAIBR made clear that equipment and home or vehicle modifications can be reimbursed from this funding allocation. As a reminder, Section B benefits are used to reimburse for injuries to which the DTPR do not apply or which are not diagnosed and treated in accordance with the protocols.
The amendments also increased the funds allocated for physiotherapy services under the Special Provisions section of the regulation to $750 (previously $600). The Superintendent of Insurance’s Office has clarified that physiotherapists can provide services valued up to this amount for non-DTPR injuries without the insurer’s input; however, after this “soft cap” has been reached the physiotherapist must obtain the insurer’s input prior to providing further treatment.
