The Federal Health Claims Processing System is the automated system that processes health claims for Veterans Affairs Canada, the Department of National Defence and the Royal Canadian Mounted Police. To administer this large and complex system, Public Works and Government Services Canada contracts the services of a private health insurer, Medavie Blue Cross. Of the three departments, Veterans Affairs Canada is the largest user accounting for 87% of the total volume of claims processed. In 2010/11, there were 13.5 million claims processed for Veterans Affairs Canada at a value of $640 million.
To protect the financial integrity of the claims processed, Medavie Blue Cross is contractually obligated to conduct investigative services of the 170,000 health care providers registered to deliver benefits or services to Veterans. The National Investigative Unit, within Medavie Blue Cross, conducts various audit activities to ensure that the health care providers are complying with the requirements. These activities include:
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analyzing claims data to identify providers whose billing practices may not comply with the requirements;
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distributing letters to Veterans to verify that benefits and services billed were actually received;
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mail audits requesting providers to submit additional documentation to support a claim submitted; and
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on-site audits where investigators will travel to the health care provider's business to meet with the staff and review the supporting documentation on location.
The purpose of these audit activities is to identify potential recoveries, educate health care providers on the billing requirements and act as deterrent to improper billing practices.