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3.0 Audit Results

3.1 Policies and Procedures

In general, policies and procedures were up-to-date and accessible online. Also, staff reported that they had received sufficient training. However, the audit team did note three recommendations.

The first recommendation relates to clarifying roles and responsibilities when treatment benefits eligibility and rehabilitation services eligibility overlap. Overlap occurs when an eligible Related Health Service - POC 12 benefit is approved and funded under the Veterans Health Care Regulations, yet also an appropriate intervention consistent with the goals of the Veteran’s rehabilitation plan. In these cases, there should be further direction to field staff to identify the appropriate delegated decision maker, which would reduce confusion and ensure coding consistency.

The second recommendation is with regard to Related Health Services - POC 12 treatments provided to Veterans in their home (in-home services). Currently, the policy indicates that payment for in-home treatment by providers can be approved by VAC and that the applicable fees for in-home treatment benefits are to be paid in accordance with Section 5 of the VHCRs. During interviews, some staff indicated that the current business processes does not describe what would be considered an appropriate fee for in-home services. Furthermore, the lack of specific benefit codes for in-home services limits the Department’s ability to monitor the frequency and expenditures related to in-home treatment. Consequently, the audit team was also unable to identify in-home treatment transactions during the file review and thus could not quantify the frequency or expenditures for in-home services.

The third recommendation relates to the inconsistent processing of Multi-Disciplinary Clinic (MDCs) transactions. MDC decisions tend to have a higher dollar value as they are a related health service plan incorporating multiple treatments. In September 2013, a new business process for treatment at MDCs was distributed. This business process specified that Hospital Services - POC 5 benefit codes are to be used for MDC services. During interviews, staff noted that many providers offering MDC services were not registered under POC 5 but instead were registered under POC 12. As a result, some staff were coding MDC services under a “miscellaneous benefit code”, while others were coding each individual service separately. Without proper coding, the Department is not able to adequately monitor the use of these services.

Recommendation 1

It is recommended that the Director General, Service Delivery and Program Management Division, updates the business processes to clarify the responsibilities of staff when treatment benefits eligibility and rehabilitation services eligibility overlap. (Essential)

Management Response

Management agrees with this recommendation. Work is currently underway to update processes and guidelines by November 2014 to clarify the responsibilities of staff when treatment benefits and rehabilitation services overlap.

Recommendation 2

It is recommended that the Director General, Service Delivery and Program Management Division, develops a business process relating to the provision of services at the Veteran’s home. (Essential)

Management Response

Management agrees with this recommendation. Work is currently underway to develop clear guidelines and processes by October 2014 to facilitate the provision of services at the Veteran’s home.

Recommendation 3

It is recommended that the Director General, Service Delivery and Program Management Division, enforces the business process for services received at Multi-Disciplinary Clinics. (Essential)

Management Response

Management agrees with this recommendation. Work is underway to ensure that the business process for multi-disciplinary clinics is enforced for all clinics of this type by July 2015 by communicating with and re-registering clinics as their current authorizations expire.

3.2 Monitoring

As part of the assessment of the management control framework, the audit team assessed key monitoring activities consisting of: quality assurance, performance measurement and account verification. A recently completed audit of POC 13 - Special Equipment (March 2014) assessed these activities and identified a recommendation to improve each one. The audit team confirmed that the observations are identical for this audit and that the recommendations presented in the audit of POC 13 - Special Equipment will address any gaps. Below is a summary of the observations presented in the audit of POC 13 - Special Equipment.

Quality Assurance is a continuous process to monitor the quality, consistency and timeliness of activities completed within the Department. During the audit of POC 13 – Special Equipment, some Client Service Team Managers indicated that they were performing these reviews, but there was no evidence to support that this was actually occurring. In response to the audit of POC 13 - Special Equipment recommendations, a national quality assurance process was established following the completion of fieldwork for this audit; therefore, the audit team was not able to assess the results or the effectiveness of the new process.

Performance measurement is the process of collecting, analyzing and reporting data in order to monitor the efficiency and effectiveness of a program or activity. This information can then be used to improve the delivery of a program. The audit team noted a Performance Measurement Plan existed for the Health Care Benefits Program. However, it did not have specific indicators for Related Health Services - POC 12 to measure performance. Additionally, this information was not being shared with senior management to support informed decision-making. In response to the audit of POC 13 - Special Equipment, specific indicators for all POCs have been developed and results are now shared with senior management.

As per the Treasury Board Directive on Account Verification, an account verification process ensures sound stewardship of public money. As part of an account verification process, transactions are reviewed for accuracy to confirm that the payment is not a duplicate, that all charges are payable and that the amount has been calculated correctly. For low risk transactions, reviewing a sample of transactions post payment is acceptable. Finance Division within VAC has determined that Related Health Services - POC 12 transactions are low risk and at the completion of fieldwork the Division was in the process of implementing a new process to analyze large volumes of low risk transactions to identify potentially problematic transactions for review.

3.3 Compliance

Table 3 presents a summary of file review results for the 100 sample payment transactions that were tested.

Table 3 - Compliance with Key Business Processes
Key Requirements Tested Percentage
Files reviewed were within limits outlined in the Benefit Grid or rationale provided when exceeding rates 99%
Services added to Veteran’s case plan (rehabilitation) 92%
Provider signature on claim form 95%
Veteran decision letter and/or provider authorization letter was retained on file 66%
Veteran’s signature acknowledging receipt of services 63%

Source: Analysis from files reviewed by the audit team

The purpose of a provider signature is to demonstrate that the submitted claim is true and accurate to the best of their knowledge. Furthermore, it confirms the provider accepts all of the terms and conditions set forth in the Benefit Provisions and Payment Guidelines for Health Services. File review results identified that 95% (95/100) of provider claim forms contained the provider signature.

A Veteran’s signature is considered a key control to confirm that services were received by the Veteran from the provider. The Benefit Provisions and Payment Guidelines for Health Services indicate that the provider claim form must be signed by the Veteran. File review results identified that only 63% of files contained a copy of the Veteran’s signature acknowledging receipt of Related Health Services - POC 12. Although the result is lower than expected, some controls did exist to reduce the risk of paying for services not provided. One control is the preauthorization of services and benefits by VAC staff. A second control is a dedicated investigative unit, operated by the contractor as part of the FHCPS contract, which regularly conducts various audit activities to ensure that health care providers are complying with the requirements. Both of these controls were operating as intended and minimized the risk. Going forward, the Department agrees that confirmation of receipt of services continues to be necessary as required under the Treasury Board’s Directive on Account Verification.

Clear communication of decisions is important to ensure that Veterans understand the rationale for the decision and, if applicable, their appeal rights. Also, letters to providers advise of details of the decision for service and can assist them when completing the claim form to request payment. Letters to both Veterans and providers form part of the supporting documentation of the decision for services. The Department utilizes letter templates to support consistent communication with Veterans and providers. The file review identified that 66% of files contained a Veteran and/or provider letter. The lack of supporting letter documentation could be addressed by the establishment of a national quality assurance process.

Recommendation 4

It is recommended that the Director General, Service Delivery and Program Management Division explores options to confirm receipt of services and obtain provider attestation. (Essential)

Management Response

Management agrees with this recommendation. Work is underway to explore options for the modernization of provider attestation and Veteran confirmation of services received. Options will be identified by April 2015.

3.4 Timeframes

Related Health Services - POC 12 rehabilitation decisions covered by the Canadian Forces Members and Veterans Re-establishment and Compensation Act are delegated to Case Managers in VAC Area Offices. The 2013 Audit of Delegated Decision Making examined timeframes for Related Health Services - POC 12 rehabilitation decisions by Case Managers. It was determined that decisions were generally made in a timely manner and no opportunities were identified to improve the efficiency of the decision-making process. Once a decision is made by the Case Manager, a CSDN work item is sent to the TAC to request an authorization for the service. Analysis of file review results noted that work items were created and sent to the TAC within one to two days of updating the Veteran’s case plan.

Related Health Services - POC 12 treatment decisions covered by the Veterans Health Care Regulations are delegated to analysts in the TAC. Providers call the TAC to request an authorization for a service on behalf of a Veteran. The audit team observed that TAC Analyst decisions and authorizations were actioned immediately upon request from the provider.

Additionally, the audit team examined the time from when a Related Health Services -POC 12 claim for payment was received at the health claims processing centre to the time payment was approved for the provider. File review results confirmed that transactions were paid within 30 days, with the majority paid within 10 days.

3.5 Audit Opinion

The audit team observed that the relevant policies and procedures were generally clear and up-to-date with only a few areas noted requiring further action. It was also noted that key monitoring activities such as quality assurance, performance measurement and post payment verification were in development. File review results identified a moderate degree of compliance with key requirements and that staff carry out their duties efficiently and exercise appropriate judgement to process requests as quickly as possible. Overall, the audit team determined the results to be "Generally Acceptable".

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