Follow-up on Audit of Canadian Forces Health Services

The guidance on the CAF claims approval process has been revised. However, the sampling methodology has not been updated.

At the suggestion of ADM(RS), CFHS is seeking advice from ADM(Fin)/CFO in order to determine an appropriate sampling methodology for the approval of claims that will meet departmental requirements.

ADM(RS) recommends that this MAP remain open to track its status.

MPC should revise the management action and/or target completion date of this MAP.

1.2 - The National Investigation Unit (NIU) at Medavie Blue Cross is mandated by contract to systematically follow-up on every high-risk claim identified by the clinics. These claims are carefully examined by the unit using diverse means including verification letters, and recoveries are made from health care providers who submit illegitimate claims. Based on the latest data provided by the NIU for the 1st, 2nd and 3rd quarter of the current FY, over 1,500 verification letters have been sent to CAF members and nearly $1,350 has been recovered from health care providers.

In addition, units will be directed to refer all non-certifiable claims, done through quarterly audits, back to Medavie Blue Cross for follow-up and recovery if applicable. CFHS will also implement a monitoring procedure to ensure that Medavie Blue Cross is following up on all non-certifiable claims and Medavie Blue Cross will be engaged to provide sufficient information to allow CFHS to ascertain that every non-certifiable claim has been reviewed. This will ensure both a local audit and response as well as a third party claims processing audit and response. This two-pronged approach will increase discovery and appropriate actions being taken.

The guidance on the CAF claims approval process has been revised to provide additional direction to units on referring non-certifiable claims back to Medavie Blue Cross. These changes do not address the second part of the MAP, which was to implement a monitoring procedure to ensure that Medavie Blue Cross is following up on all non-certifiable claims.

At the suggestion of ADM(RS), CFHS is seeking advice from ADM(Fin)/CFO in order to update its monitoring procedures for Medavie Blue Cross.

The risk remains that not all non-certifiable claims are being reviewed and appropriately resolved as required.

ADM(RS) recommends that this MAP remain open to track its status.

MPC should revise the management action and/or target completion date of this MAP.

The guidance on the CAF claims approval process has been revised. However, these changes were minor and the sampling methodology has not been updated.

Limited progress has been made to strengthen the claims reconciliation and pre-authorization processes. This includes the quarterly post-payment verification, a key control activity. At the suggestion of ADM(RS), CFHS is seeking advice from ADM(Fin)/CFO to ensure that controls related to the payment process will meet departmental standards. This includes strengthening the sampling methodology and improving the financial control framework for claims reconciliation and pre-authorization.

ADM(RS) recommends that this MAP remain open to track its status.

MPC should revise the management action and/or target completion date of this MAP.

CFHS has initiated a plan to cap physician fees to align with provincial fee guides in all jurisdictions across Canada. Under this plan, Medavie Blue Cross will apply dollar maximums for each type of service billable by physicians, with any overbilling being cut back to the maximum allowed. Based on a historical analysis of physician costs billed through FHCPS, anticipated cost savings are forecast to exceed $5.5 million annually in comparison to current costs.

CFHS is presently executing a communication strategy to announce these changes to the provider community, including medical associations, in order to mitigate risks associated with implementing the fee cap. Cost savings achieved by this initiative will be identified through the quarterly financial reporting processes and closely monitored by CFHS.

CFHS has not implemented a cap on physician fees to align with provincial fee guides. Instead, an updated strategy of “Cost Controls for the FHCPS contract” is being pursued. This strategy was approved by the Surgeon General in 2018 and includes the following elements:

• to conduct an analysis on ▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓
• to conduct an analysis ▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓▓
• to conduct an analysis on how to implement a “cap system” where provincial fee rates do not exist;
• to ascertain the feasibility of simply adopting all of Veteran Affairs Canada’s codes and medical procedure rates that may or may not include a premium;
• to explore the use of data analytics to identify potential efficiencies, cost savings and other timely and relevant information to the Directorate of Quality and Performance for clinical governance analysis.

As part of the delivery of this strategy, CFHS approached ADM(RS) in 2017 for advice on how to better use information from the FHCPS contract. ADM(RS) conducted an advisory engagement on this topic in conjunction with this audit follow-up, which will be reported separately.

CFHS anticipates full implementation of its new strategy by March 2019, which will consider the recommendations from the ADM(RS) Advisory Report on Information Management in the FHCPS Contract.

ADM(RS) recommends that this MAP remain open to track its status.

MPC should revise the management action and/or target completion date of this MAP.

CFHS is working with the CFHS units across the CAF to ensure that timesheet verification is appropriately done and at the right level. Written direction was sent to the units in September 2013 outlining the responsibilities of the Clinic Managers and their delegated staff in reviewing timesheets. Further direction was also given at the CFHS Comptroller workshop in February of 2014.

CFHS and Director General Procurement Services have also established a review system with the Contractor whereby the Contractor sends a copy of selected timesheets that have been identified as discrepancies by the Procurement Authority during the detailed review of each monthly invoice. Appropriate corrective actions, including financial recovery, are taken by the Contractor each month as required as a result of this detailed review.

This action was completed in February 2014 during the course of the original audit, and had been assessed as completed at the time that the report was presented to the Departmental Audit Committee in March 2014.

There is no further progress to report on this MAP as it has been closed.

As part of the CFHS L2 Strategic Business Plan for FY 2018/19, CFHS examined and considered the risk, mitigation strategies and available courses of action in the employment of uniformed health care providers, public service health care providers and the dependence on the civilian health care system in order to maintain the required level of care. Though different from what was planned in the original MAP, the holistic examination of personnel in the delivery of health care sufficiently addresses the intent of the recommendation.

ADM(RS) recommends that this MAP be closed.

The CFHS performance measurement framework is an evolving system that is constantly under review and revision, to ensure it remains dynamic and responsive to the health support needs of the CAF and its soldiers. The Performance Measurement Cell will continue to review and revise performance indicators through a logic modeling process. Particular focus will be given to revision and creation of appropriate performance indicators related to the management and performance of the FHCPS contract and The Health Services Support contract.

CFHS performance management stakeholders will be deliberately and systematically consulted to clarify data requirements and computation methodologies of all strategic performance indicators. Once confirmed and collated, both data collection requirements and indicator methodologies will be distributed to all personnel involved in data collection and reporting. A calendar detailing the schedule of indicator data requirements will also be developed and distributed. The Chain of Command will be engaged at the operational and tactical levels to improve data quality. Further, the CFHS Performance Measurement Cell will engage clinic managers at their annual national forum with the aim of providing formal structured guidance on performance measurement at the tactical level.

CFHS has identified 57 performance measures in the management of health services. These are part of a logic model comprised of clinical, technical and managerial measures and are reported annually.

In addition, CFHS’ program and services were accredited by an independent third party using industry-standard performance indicators. The accreditation process confirms that CFHS has met national standards for health care in Canada and has shown a commitment to quality improvement. The accreditation is completed once every four years, and is currently valid until 2021, provided that program requirements continue to be met.

Finally, CFHS has also developed a logic model for the FHCPS contract (Oct 2017) and a logic model for the Health Care Providers contract (Jan 2018), which is the successor to the Health Services Support contract. Depending on the specific performance metrics in these logic models, they intend to measure them, monthly, quarterly and semi-annually.

ADM(RS) recommends that this MAP be closed.