Health Canada/Canadian Assisted Devices
Association
Working Group
Update on Medical Supplies and Equipment (MS&E)
Audit Program
March 26, 2012
Toronto, On
PRESENTATION OBJECTIVES
• Overview of NIHB Program
• Audit Program
• Current Context and Emerging Issues
HELL….
Another
Random
Audit….tHEy
never stop!
AND the
rules keep
changing!!
The talks have begun, but there is no sign NIHB audit woes will
abate soon.
NIHB PROGRAM
• Program is publicly funded and as such is
accountable for those public funds.
• The NIHB Program is not an insurance carrier. We
differ from private insurance plans in a number of
ways:
Needs based approach
No co-payments
No deductibles
No annual maximum
NIHB PROGRAM PRESSURES
•
•
•
•
•
Financial
Political
Media
Provincial and Territorial Governments
Stakeholders,
•
•
•
•
Professional Associations,
Retail and Corporate Medical Industry Organizations
Pharmaceutical Industry
Medical Lobbyists
• First Nations and Inuit Clients and their Rep Orgs
Program Overview
• The NIHB client population was 846,024 as of March 31, 2011
soon to be about 900,000
• A total of 20,197,466 pharmacy, MS&E and dental claims lines
were settled through the HICPS system in 2010/11.
• As of March 31, 2011, 25,710 active providers were registered
with the HICPS claims processor to deliver NIHB Pharmacy,
MS&E and Dental benefits.
Program Expenditures
NIHB Benefit
Pharmacy (including MS&E)
Medical Transportation
Dental
Vision Care
Premiums
Other Health Care
Total NIHB Expenditures
2010/11 Expenditures
($ Millions)
% of Total NIHB Expenditures
$440.8
$311.8
$215.8
$29.2
$18.4
$12.1
$1,028.1
42.9%
30.3%
21.0%
2.8%
1.8%
1.2%
100%
Source: FIRMS adapted by Program
Analysis Division
Medical Supplies & Equipment
Overview
• A total of 50,462 clients received MS&E benefits in
2010/11.
• During 2010/11, 309,874 MS&E claim lines were
processed through HICPS.
• In 2010/11, 3,219 providers submitted claims for MS&E.
• In 2010/11, expenditures for MS&E paid through HICPS
totalled $27.5 million or 6.3% of all NIHB Pharmacy costs.
• The Alberta Region (20.5%) and Saskatchewan Region
(17.3%) had the highest proportions of MS&E costs.
NIHB Medical Supplies, 2010/11
35%
30%
25%
20%
29.3% NIHB Medical Supplies by Category and Claims Incidence, 2010/11
23.0%
17.2%
15%
10%
8.1%
8.1%
6.4%
5%
4.5%
3.4%
Oxygen
Supplies
Catheter
Supplies
0%
Wound Care Incontinence Hearing Aid Bandages
Supplies
Supplies
Supplies
Ostomy
Supplies
All Others
Expenditures for Hearing Aids totalled $4.2 million, followed by Wheelchairs
and Accessories at $2.9 million, and Custom Made Footwear at $2.4 million
Why does Health Canada have an Audit Program?
NIHB RISK MANAGEMENT INITIATIVE
• Financial Administration Act (FAA) is the key legislation for
Federal Government Departments to ensure that public
funds are distributed appropriately
• Following recommendations from the Auditor General, Public
Accounts Committee and independent consultants, the NIHB
Program implemented a Risk Management Framework and
a Risk Management Committee
• Goal of the initiative is to reduce financial risk to the Crown
through diligent oversight of expenditures of public funds.
PROVIDER AUDIT PROGRAM
Scope:
• The Pharmacy Provider Audit Program is administrative in
nature and is aimed at detection, prevention and settlement
of inappropriate billing practices.
Objectives:
• Prevent and detect inappropriate billing practices
• Validate active licensure of registered providers
• Confirm paid services were received by eligible NIHB
program clients
• Ensure that providers have retained appropriate
documentation to support submitted claims
PROVIDER AUDIT COMPONENTS
•
•
•
•
•
Next Day Claims Verification Program
Client Confirmation Program
Provider Profiling Program
On-Site Audit Program
Desk Audit Program
NIHB Medical Supply and Equipment
Audit Program
As a MS&E service provider you should be familiar with
the following important information:
• The Provider Guide for MS&E Benefits
• The Provider Claims Submission Kit
• http://www.provider.esicanada.ca/
The above information provides you with the Terms and
Conditions of the Program including policies and
claim submission requirements.
What do you need to know to bill the Program?
Prior Approvals (PAs)
• PA’s currently approved by HC regional
offices.
• PAs approve the benefit to be provided and
not the cost of the item.
• Cost on PAs should be the lesser of the
Actual Acquisition Cost (AAC) plus
applicable regional mark-up or regular retail
price.
Core elements for claim submission are as
follows:
A valid prescription (Rx).
• must be signed by an NIHB recognised
prescriber for the service being rendered
• Include patient name, date
• Rx should itemise the requested services to
be rendered
• E.g; bandages, what type? size? Etc
A complete client chart/record which includes:
• Internal Invoice supporting all financial
transactions
• Actual Acquisition cost of items should be
made available if not in client file
• Proof of NIHB Program client receipt
• Chart notes in support of all professional
assessments
• Copy of prior approval
Inappropriate Billing Practices
• Charging maximum rate in lieu of actual acquisition
cost plus applicable mark-up
• False claims
• Billing for items requiring a prior approval (PA) that
were not submitted to the FNIH Regional Office for
review and approval
• Offering incentives in return for NIHB claims
• Charging “bonus sizes” to the Program instead of
original pack size
• Billing non benefits under codes which are covered
MS&E Audit Program
Current Observations
•Over the last 5 years, the NIHB Program has
conducted 56 onsite audits of MS&E providers
nationally
•Recoveries for this time period amounted to
$258,194
Changes to NIHB Program (MS&E)
• Currently a moratorium on audits of the following:
• custom-made products
• Mobility & Equipment items
• Pricing Certainty
• The Program is moving towards defined price files for claims
adjudication. Eliminating the need for most pricing audits
• Replace PA with Special Authorization cut the frequency of
interaction 1/24 months from 8/24 months
Questions?
Non-Insured Health Benefits
For more information regarding the Non-Insured
Health Benefits Program please visit the Health
Canada’s First Nations and Inuit Health Branch
website.
http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/indexeng.php