Essays academic service


A case study audit report of veterans affairs association

Clients are provided with a Health Care Identification Card which indicates the Programs of Choice for which they have eligibility.

Each Program of Choice has a unique Benefit Grid which defines the treatment benefits approved for that particular program. Clients present their health card along with required prescriptions to the health care provider of their choice.

Providers verify eligibility, and when necessary, obtain authorization from one of several authorization units which have been established to administer the programs. Additional information associated with processes used to deliver the Treatment Benefits Program is presented in Section 1.

To address the audit objectives, fieldwork was conducted in the operational areas involved with the delivery of the Treatment Benefits Program. As well, audit work was conducted in units which have functional management responsibility for the program.

Audit assurance is being provided associated with the following audit objectives: Appropriate audit procedures have been conducted and sufficient evidence obtained to provide this assurance and support the findings contained in this report. Conclusions by Audit Objective: To assess the adequacy of the Department's management control framework regarding the benefits provided through the Programs of Choice The audit identified a number of opportunities to improve the administration of the program, including: Historically, VAC has not dedicated sufficient resources to this activity and for some of the Programs of Choice the edits had not been updated for a number of years.

Dollar limit edits had not been established for all benefits covered by the program.

This results in providers being reimbursed for amounts claimed, without verifying if rates charged are reflective of market rates.

Controls contained in the Benefit Grids to ensure that provincial programs are accessed had not always been activated.

  1. Historically, VAC has not dedicated sufficient resources to this activity and for some of the Programs of Choice the edits had not been updated for a number of years. Recommendation 1 Essential It is recommended that the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch in consultation with the Assistant Deputy Minister, Service Delivery and Commemoration Branch ensure the recently adopted program management structure for the Treatment Benefits Program is fully implemented, including clearly defining and communicating the roles and responsibilities of units and staff engaged in the management and delivery of the program.
  2. Historically, VAC has not dedicated sufficient resources to this activity and for some of the Programs of Choice the edits had not been updated for a number of years. As well, audit work was conducted in units which have functional management responsibility for the program.
  3. After conducting preliminary planning to address this audit objective a number of factors were identified which resulted in the decision to exclude transaction testing during the audit. Much of the information being used to manage the program was being extracted from the FHCPS using ad hoc queries or with manually prepared reports.
  4. Recommendation 4 Essential It is recommended that the Assistant Deputy Minister, Service Delivery and Commemoration Branch in consultation with the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch implement a process to conduct quality reviews for the Treatment Benefits Program to ensure compliance with regulatory and policy requirements, to assess the consistency of service delivery and to identify areas where changes are required to programs, policies and processes.

As well, a clear strategy is needed to define where agreements with health care provider associations are required for each of the Programs of Choice. To determine the degree of compliance with applicable policies The audit originally planned to sample transactions and conduct compliance testing against VAC legislative and policy requirements for the Treatment Benefits Program.

After conducting preliminary planning to address this audit objective a number of factors were identified which resulted in the decision to exclude transaction testing during the audit.

Some of these factors included; policies for the program require significant updating and consolidation, a major review of the Benefit Grids was underway and improvements are required to management processes used to monitor program delivery's compliance with policy. The audit contains recommendations to update and consolidate policies and procedures for the program. To assess the adequacy of information used for decision making and reporting Improvements are required to the provision of information and regular reporting to operational, functional and senior managers associated with the Treatment Benefits Program.

  1. Dollar limit edits had not been established for all benefits covered by the program.
  2. Detailed recommendations contained in this report are listed below.
  3. Additional information associated with processes used to deliver the Treatment Benefits Program is presented in Section 1.
  4. Completion of the review of the Benefit Grids, currently in progress, which will define the benefits and services to be covered by the Treatment Benefit Program and the associated program rules, is seen as an important first step to improving overall administration of the program.

Much of the information being used to manage the program was being extracted from the FHCPS using ad hoc queries or with manually prepared reports.

To identify opportunities to reduce the number of benefit codes used to process treatment claims Based on the analysis of claims data, the greatest opportunity to reduce the number of Benefit Codes transactions being used to deliver the Treatment Benefits Program without negatively impacting client benefits, appears to be in the Health Related Travel, Audio Services, Prescription Drugs and Vision Care Programs of Choice.

Executive Summary

The recommendations contained in this report are intended to improve the management and delivery of the program. It is acknowledged that new program management structures which were being put in place at the time of the audit should address many of the findings contained in this audit report.

  • To identify opportunities to reduce the number of benefit codes used to process treatment claims Based on the analysis of claims data, the greatest opportunity to reduce the number of Benefit Codes transactions being used to deliver the Treatment Benefits Program without negatively impacting client benefits, appears to be in the Health Related Travel, Audio Services, Prescription Drugs and Vision Care Programs of Choice;
  • Completion of the review of the Benefit Grids, currently in progress, which will define the benefits and services to be covered by the Treatment Benefit Program and the associated program rules, is seen as an important first step to improving overall administration of the program;
  • To assess the adequacy of information used for decision making and reporting Improvements are required to the provision of information and regular reporting to operational, functional and senior managers associated with the Treatment Benefits Program;
  • Recommendation 9 Important It is recommended that the Director, Disability Benefits and Treatment Benefits Program determine where agreements with provider associations are required and assign responsibility for their negotiation and maintenance;
  • As well, audit work was conducted in units which have functional management responsibility for the program.

Completion of the review of the Benefit Grids, currently in progress, which will define the benefits and services to be covered by the Treatment Benefit Program and the associated program rules, is seen as an important first step to improving overall administration of the program. The audit report contains 12 recommendations of which 6 are deemed essential and 6 important, see Annex C for a definition of the significance of the observation.

Language selection

Detailed recommendations contained in this report are listed below. Recommendation 1 Essential It is recommended that the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch in consultation with the Assistant Deputy Minister, Service Delivery and Commemoration Branch ensure the recently adopted program management structure for the Treatment Benefits Program is fully implemented, including clearly defining and communicating the roles and responsibilities of units and staff engaged in the management and delivery of the program.

Recommendation 4 Essential It is recommended that the Assistant Deputy Minister, Service Delivery and Commemoration Branch in consultation with the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch implement a process to conduct quality reviews for the Treatment Benefits Program to ensure compliance with regulatory and policy requirements, to assess the consistency of service delivery and to identify areas where changes are required to programs, policies and processes.

Recommendation 7 Important It is recommended that the Assistant Deputy Minister, Service Delivery and Commemoration Branch determine how changes to business processes could be implemented to reduce the requirement to have cases adjudicated by the Exceptional Benefits and Head Office Appeals Units.

Search and menus

Recommendation 9 Important It is recommended that the Director, Disability Benefits and Treatment Benefits Program determine where agreements with provider associations are required and assign responsibility for their negotiation and maintenance. Recommendation 10 Essential It is recommended that the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch in consultation with the Assistant Deputy Minister, Service Delivery and Commemoration Branch review and update existing policies and procedures for the Treatment Benefits Program, create new policies and procedures where required and consolidate this information in one location.

Recommendation 11 Essential It is recommended that the Senior Assistant Deputy Minister, Policy, Programs and Partnerships Branch determine the regular reporting needs of operational, program and senior management associated with the Treatment Benefits Program and place these reports in production.