Provider Audits - Medical Supplies and Equipment
 The
Provider Audit Program assesses that provider claims are billed in compliance
with the Terms and Conditions of the Non-Insured Health Benefits Program.
The objective of the audit program is to ensure that the Non-Insured
Health Benefits (NIHB) Program is appropriately billed by providers for
the benefits and services provided in conformity with NIHB policy.
Overview
Audit Objectives
Audit Components
Stages of the On-Site Audit
Reference Documents
Additional Information
Overview
The overview is intended to provide a better understanding of the medical
supplies and equipment (MS&E) provider audit process and the requirements
for claims adjudication under the NIHB Program. The audit activities
are based on generally accepted industry practices and accounting principles
and may be carried out, up to two years from the date a prescription
is dispensed.
As a publicly funded Program, it is a federal requirement to account
for the expenditure of those public funds. The MS&E Provider Audit
Program contributes to the fulfillment of this overall requirement. The
agreement signed by providers allows First Canadian Health (FCH) to verify
paid claims against MS&E records.
On behalf of the NIHB Program, FCH conducts administrative audits of
paid claims for services rendered to NIHB clients. All audit activities,
from the selection of providers for audit, to issuance of audit documentation
to providers regarding the findings, are approved by representatives
of the NIHB Program.
The NIHB Program and FCH Management Inc. highly regard and value the
services provided to NIHB Program clients. The purpose of the Audit Program
is to share with providers information about proper billing conditions,
and to verify paid claims against the NIHB Program requirements.
The following overview outlines the objectives and components relating
to the audit of claims on behalf of the NIHB Program.
Audit Objectives
The objectives of the FCH Provider Audit Program are as follows:
- to ensure that providers have retained appropriate documentation,
meeting both provincial and federal regulations as well as program
requirements, in support of each claim, in accordance with the Pharmacy/MS&E
Provider Agreement;
- to ensure that services paid for were received by NIHB clients;
- to detect billing irregularities;
- to validate active licensure of the providers.
Audit Components
The components of the FCH Provider Audit Program are outlined below.
To carry out the Next Day Claims Verification and On-Site Audit Program,
FCH requires access to the following information:
- Client's profile
- Original prescription
- Shipping invoices
- Internal invoices
- Documentation of item receipt by the client
- Evidence of additional coverage (to coordinate benefits)
Next Day Claims Verification Program - Consists of
a review of a defined sample of claims submitted by service providers
the day following receipt by FCH. Service providers may be contacted
to provide copies of prescriptions and/or invoices as well as any other
supporting financial data. Any errors detected through this process will
result in the claim being reversed.
Client Confirmation Program - Consists of a quarterly
mailout to a randomly selected sample of NIHB clients to confirm the
receipt of the benefit that has been billed on their behalf.
Provider Profiling Program - Consists of a review
of the billings of all service providers against selected criteria and
the determination of the most appropriate follow up activity if concerns
are identified. All claims are subject to review by audit. Any claims
not meeting Program criteria will be subject to audit reclaim.
On-Site Audit Program - Consists of the selection
of a sample of claims for validation with a service provider's records
through an on-site audit.
On-Site Audit Program
Providers are not randomly selected for audit. Providers may be selected
for an on-site audit as a result of information gained through the above
three components and any additional information received. FCH
contacts the provider at least three weeks prior to
the proposed on-site audit date. Every effort is made to accommodate
the audit date with the provider's schedule. The date agreed upon for
the on-site audit is confirmed by fax with the provider.
Stages of the On-Site Audit
Pre-Audit/Entrance Interview
Upon arrival, the auditors will introduce themselves, meet with the
business staff who will be involved in the audit, and provide an explanation
of the audit process. The provider will be asked to describe the records
filing system for clients, and whether the documentation for claim transactions
are maintained on hard copy or electronically on the client's profile.
The provider will be asked whether the prescription records under review
are to be retrieved by the provider staff or the auditors. The auditors
will indicate to the provider that a post-audit summary will be provided
at the end of the on-site audit.
Conduct of the On-Site Audit
The purpose of the on-site audit is to verify paid claims against provider
records. At the end of each audit day, a list of prescriptions or documents
not found by the auditor will be provided to the provider. The provider
has the opportunity to locate and supply the documentation to the auditor
the next audit day. If any documents are not located by the end of the
on-site audit, the provider has the opportunity to send these documents
to the auditor within two weeks of the end of the audit. Claims not supported
by the required documentation will appear as recoveries in the audit
letter and report to the provider.
Post-Audit Interview
At the end of the on-site
audit, the auditor will provide a general overview of the categories
of errors found. The final audit results will not be complete until the
auditor has conducted additional analysis, such as, but not limited to,
client and prescriber confirmations. During the post-audit exit interview
the provider will be given a standard checklist to complete and send
to FCH, which serves to confirm the audit process conducted at the respective
on-site audit.
Audit Report
A report of the audit findings will
be sent to the provider within 60 days of the on-site audit. If there
are delays in meeting this deadline, a letter will be sent to the provider
advising of the delay and the revised delivery date for sending the audit
letter and report. Once the audit letter and report are received, and
in the event that there are audit observations resulting in recovery
of claims, the provider has 30 days to respond to FCH. If the provider
needs additional time to respond, a request for additional time can be
sent in writing to FCH.
Within 60 days of the response from the provider, FCH will send a letter
and a report of the final audit findings to the provider. In the event
that there are final audit findings resulting in recovery of claims,
the provider has 30 days from the date of the letter to respond to FCH.
Failure to respond within 30 days of the 2 nd letter, will result in
a withhold against the provider's payment statements until recovery is
paid in full.
Guidelines
The audit activities are based on generally accepted industry practices
and accounting principles and may be carried out up to a maximum of five
years from the date of service.
The provider must maintain records relating to NIHB clients and their
prescriptions in accordance with all applicable laws. All records shall
be treated as confidential so as to comply with all applicable provincial
and federal legislation regarding the confidentiality of patient records.
A separate valid prescription (as defined by federal and provincial legislation)
is required for each member of a family for the reimbursement of claims
submitted under the NIHB Program.
As part of the audit process, FCH may contact the prescribing physician
to verify clients and prescriptions and contact the client to substantiate
the receipt of the item and the specific claim information.
As a provider registered to submit claims under the NIHB Program, the
provider in accordance with the First Canadian Health Management Corporation
Inc. Pharmacy/MS&E Provider Agreement will assist FCH, or a third
party authorized by FCH, by:
- Granting access to the provider's premises, during the provider's
normal business hours, to inspect, review and reproduce any medical
supplies and equipment records maintained by the provider pertaining
to NIHB claims;
- Providing access to all relevant documentation such as, but not limited
to, client's profile, original prescriptions and cancelled or revoked
prescriptions; shipping invoices; and
- Responding to requests for documentation via mail or fax within
the specified response time.
Providers will be advised of any audit findings and will have the opportunity
to respond to the audit findings within 30 days from the receipt of the
audit report. FCH will consider further documentation a provider may
wish to submit in support of its claim. Once the audit report has been
finalized, all overpayments must be corrected by the provider remitting
a cheque payable to FCH.
NIHB may refer concerns arising from such audits, to the appropriate
federal, provincial or territorial professional regulatory bodies or
the RCMP.
Reference Documents
- FCH MS&E Provider Agreement
- FCH MS&E Provider Information Kit
- NIHB/FCH Newsletters -- issued quarterly
- NIHB Program MS&E Bulletins
- NIHB/FCH MS&E Newsletters
Additional Information
 Providers
requiring additional information about the FCH/NIHB Provider Audit Program
may contact
the FCH Director of Provider Audit in writing.
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