Recommendation No. 1

It is recommended that the Assistant Deputy Minister of the First Nations and Inuit Health Branch (FNIHB) ensure that staff, who are involved in the predetermination process receive current Procedures and User Manuals with respect to using the Health Information and Claims Processing Services (HICPS) system.

Accept

FNIHB agrees with the need to provide clear predetermination procedures and an up-to-date system user manual. The manuals were marked "draft" to reflect the fact that the content was being regularly updated.

A Dental Operations Manual, that consolidates existing procedures and guidance, is being finalized and will be kept evergreen as a successor to the Dental Desktop Procedure Manual. The HICPS User Manual will continue to be regularly updated and systematically communicated to the users as has been the case in the past.  The word "draft" will be replaced with a reference to the date of the revision.

Ensure the current HICPS user manual and the future System User Manual (SUM) continues to be updated as needed and provided to staff.

The Dental Operations' Manual will be approved and disseminated to all Pre-determination staff in headquarters (HQ) and in the Region and will kept evergreen.

The new HICPS System User Manual (SUM) being developed will include a version control marker, will be maintained and made available to all relevant pre-determination staff through the HICPS Document Reporting Module and used for User training starting September 2009.

NIHB will continue to review reports on distribution of User Manual Updates to ensure the information is available for relevant users.

Ongoing

Director Operations Services and System Division (OSSD)

Recommendation No. 2

It is recommended that the Assistant Deputy Minister of the First Nations and Inuit Health Branch enhance the Health Information and Claims Processing Services (HICPS) system to ensure that the eligibility frequency limits are completely recorded.

Accept

FNIHB agrees with the recommendation and has added a system enhancement as part of the renewal of the Health Information and Claim Processing Services contract.

The New HICPS system will enable the control of frequency limitations under pre-determination.

Procedures approved through pre-determination will now be calculated in the frequency limitation. Where appropriate pre-determination staff will be able to override frequency limitation.

Recommendation No. 3

It is recommended that the Assistant Deputy Minister of the First Nations and Inuit Health Branch review and update the Health Information and Claims Processing Services (HICPS) System to reflect the operational demands of the NIHB Program.

Accept

FNIHB agrees with the recommendation and has built functionality to track post-approvals in the new HICPS system.

The new HICPS will allow tracking of post-approvals independently from pre-determination.

Implementation of new HICPS system.

December 2009

Director OSSD

Recommendation No. 4

It is recommended that the Assistant Deputy Minister of the First Nations and Inuit Health Branch ensure that there is a more effective process in place for referring cases of questionable billing practices for review and follow-up for both next day claim verifications and client confirmation letters.

Accept

FNIHB agrees that a formal mechanism to demonstrate that this information is brought forward for on-site audit consideration will further strengthen the provider audit program.

Management will add a step in the audit procedures as outlined in the Administrative Procedures Manual to ensure that there is tracking, follow-up and status updates on any cases referred to the onsite audit program as a result of information collected through the Next Day Claims Verification and Client Confirmation processes.

Revisions to the current Dental Audit Administrative Procedure Manual (APM) to describe and document the current referral practice.

April 2009

Directors PAD/OSSD

Recommendation No. 5

It is recommended that the Assistant Deputy Minister of the First Nations and Inuit Health Branch ensure that the audit procedures in place have relevance and that the Administrative Procedures Manual be updated accordingly.

Accept

FNIHB agrees with the need to ensure provider audit practices are fully consistent with approved procedures manuals.

FNIHB recognizes that changes have been made over time in the procedures followed by auditors under the direction of NIHB without being fully documented in the Administrative Procedures Manual. This will be corrected.

The Dental Audit Process documentation is being updated.

The program is taking advantage of the implementation of the new HICPS system to enhance its Dental Audit Profiling process building on the tests performed in the past and success of the pharmacy audit profiling method.