2.21 The Medical Care Plan Beneficiary Registration System. Introduction

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1 2.21 Te Medical Care Plan Beneficiary Registration System Introduction Te Newfoundland Medical Care Plan (MCP) was introduced in Newfoundland and Labrador on 1 April It is a plan of medical care insurance designed to cover te cost of pysician services for residents of te Province. A resident is defined by te Newfoundland Medical Care Insurance Act, 1999, as a person lawfully entitled to be, or to remain in Canada, wo makes is or er ome and is ordinarily present in te Province of Newfoundland and Labrador, but does not include a tourist, transient or visitor of te Province. Prior to 1 April 2000, MCP was administered by te Newfoundland Medical Care Commission. On 1 April 2000, Government dissolved te Commission and MCP became a division of te Department of Healt and Community Services. Upon approval by te Department of an application for coverage under te Medical Care Plan, te person is issued a beneficiary card. Tis card contains a unique and usually lifetime identification number and provides access to coverage under te Medical Care Plan. On average over te last tree years, te Department as issued 15,000 new beneficiary cards eac year and as at December 2002, tere were 984,089 beneficiaries recorded in te Medical Care Plan system. Expenditures for te Medical Care Plan for te last tree years ended 31 Marc are outlined in Figure 1. Figure 1 Department of Healt and Community Services Newfoundland Medical Care Plan Expenditures Years Ended 31 Marc ($ Millions) Fee-for-service Pysicians $118.9 $118.1 $115.1 Salaried Pysicians Emergency Services Out-of-Province Dental Sessional Oter Total $206.5 $197.3 $188.5 Source: Audited financial statements of te Province of Newfoundland and Labrador Auditor General of Newfoundland and Labrador 321

2 2.21 Te Medical Care Plan Beneficiary Registration System Scope and Objectives We completed our review of te Medical Care Plan Beneficiary Registration System at te Department of Healt and Community Services in Marc Te objective of our review was to determine weter te Department as adequate systems and controls to ensure tat: only eligible residents become beneficiaries under te Medical Care Plan; and te information recorded in te Medical Care Plan Beneficiary Registration System is complete and accurate so tat payments are made only on bealf of eligible beneficiaries of te Medical Care Plan. Conclusions Te Newfoundland Medical Care Plan was introduced in Newfoundland and Labrador on 1 April For te year ended 31 Marc 2003, payments under tis system totalled $206.5 million. It is a plan of medical care insurance designed to cover te cost of pysician services for residents of te Province. Due to weaknesses in controls over beneficiary registration, te lack of security features contained in beneficiary cards, and weaknesses over monitoring claims paid, tere could be a significant cost to te Province associated wit te payment of ineligible claims. Specifically: Controls over te Medical Care Plan registration process require improvement in tat te Department currently accepts potocopies of original documents wic can be easily altered or falsified. In addition, information on applications processed relating to annual newborns is not validated wit provincial vital statistics registries to ensure applicants are eligible to receive coverage under te Plan. For example, in , 5,500 applications relating to newborns were processed witout validation wit provincial vital statistics registries. Te beneficiary card requires improvements in tat it only contains te beneficiary name and number, and does not provide adequate safeguards to identify te user in order to ensure tat only eligible beneficiaries receive medical services. Te card does not ave any security features unique to te user suc as a picture or description and does not contain an expiry date. As well, te Province as never re-registered beneficiaries and te cards tat were issued in 1969 wen te Plan was introduced are still valid today. As a result, te Department cannot ensure tat only eligible beneficiaries receive medical services. 322 Auditor General of Newfoundland and Labrador

3 2.21 Te Medical Care Plan Beneficiary Registration System At December 2002, tere were 81,350 more beneficiary numbers issued tan tere were residents in te Province. Altoug some of te difference may be accounted for by various factors including deceased card olders wose deats ave not been reported to te Department, and former residents wo ave left te Province, te Department does not ave te information necessary to determine tis. It is possible for medical services to be obtained and payments made relating to tese 81,350 beneficiary cards. Te Department cannot determine ow muc, if any, as been paid on bealf of ineligible beneficiaries. In 2003, $320,000 and in 2002, $318,000 was paid for out-ofprovince medical care services relating to terminated or invalid beneficiary numbers because te Department is required under reciprocal billing arrangements to pay for tese medical services. Under reciprocal agreements wit oter provinces and territories, te Department pays for medical services provided to bot terminated and invalid (i.e. number not in Registration System) beneficiary numbers used in oter provinces and territories. At December 2002, tere were 371,144 cards tat ad been designated as terminated in te Registration System and wic could be used in any oter province or territory of Canada. Tis igligts te need for te Department to institute stronger controls over its cards by te use of expiry dates, unique identifiers and requiring periodic re-registration. Te Department is not adequately investigating wy payments are made for out-of-province medical services for individuals wo are not eligible for coverage under te Province s Medical Care Plan. Altoug montly reports are produced wic are designed to determine beneficiary eligibility relating to out-of-province payments, at te time of our review te Department ad only contacted beneficiaries listed in its May 2002 report and no work as been started on te montly reports generated since tat time. Findings and Recommendations 1. Registration An application for coverage under te Medical Care Plan can be submitted in person at te Department s offices in St. Jon s and Grand Falls- Windsor, or by mail. Applications must be accompanied by proof-ofidentity documents to prove eligibility for coverage under te Plan. Canadian citizens must present documents wic confirm teir citizensip status. Suc documents could include a Social Insurance Auditor General of Newfoundland and Labrador 323

4 2.21 Te Medical Care Plan Beneficiary Registration System Card, a Canadian passport, a Canadian birt certificate, an official Federal Government Identity Card, or Federal Government document containing te person s Social Insurance Number and name. Foreign applicants must present te appropriate immigration documents from Citizensip and Immigration Canada. Te applications are reviewed by staff of te Department of Healt and Community Services for accuracy, completeness and proof-of-identity documents. Once an application is approved, te applicant is assigned a Medical Care Plan beneficiary number and issued a card tat is to be presented wen obtaining eligible medical services. Te information is ten recorded in te Department s Medical Care Plan Beneficiary Registration System wic is necessary for processing medical claim payments. We reviewed te documentation on file at te Department to support te issuance of a Medical Care Plan beneficiary card. Our review of te registration process indicated tat te Department cannot ensure tat only eligible persons receive a beneficiary card. For example: Te Department does not require original documentation to be presented in order for a person to receive a beneficiary card. Te Department will accept potocopies of documents to support eligibility, tereby providing an opportunity for a person to modify or falsify information to gain eligibility. Information on applications processed relating to annual newborns is not validated wit provincial vital statistics registries to ensure applicants are eligible to receive coverage under te Plan. For example, in , 5,500 applications relating to newborns were processed witout validation wit provincial vital statistics registries. Te Department will register a newborn wen te request is accompanied by a parent s beneficiary card. Validation of birt information would ensure tat only eligible newborns are issued a beneficiary card. 2. Medical Care Plan Beneficiary Card Once a person is provided wit a beneficiary card, tey ave access to qualifying medical services free of carge. As a result of te cost to te Province of providing suc services, it is important tat te beneficiary cards be adequately controlled to ensure tat tey are used by only eligible persons. 324 Auditor General of Newfoundland and Labrador

5 2.21 Te Medical Care Plan Beneficiary Registration System We reviewed te controls in place at te Department over te design and use of beneficiary cards. Our review of tese controls indicated tat tere were significant weaknesses wic could result in payments being made on bealf of ineligible persons. For example: (a) Card Design In Newfoundland and Labrador te beneficiary card only contains te beneficiary name and number and terefore does not provide adequate safeguards to identify te user in order to ensure tat only eligible beneficiaries receive medical services. Te card does not ave any security features unique to te user suc as a picture or description wic could reduce te risk of ineligible use of te card. In addition, te beneficiary card does not contain an expiry date. An exception to tis relates to te issuance of a temporary beneficiary card, wic as an expiry date, to immigrants working in te Province, students wit visas, and residents wo require outof-province coverage for a maximum of 12 monts. Te use of an expiry date would require te card older to re-register on a regular basis wic would assist te Department in ensuring tat te individual still qualified for medical coverage. Te Province as never re-registered beneficiaries and te cards tat were issued in 1969 wen te Plan was introduced are still valid today. As sown in Figure 2, most oter provinces and territories use unique identifiers, ave an expiry date on teir beneficiary cards, and re-register teir beneficiaries on a regular basis. Auditor General of Newfoundland and Labrador 325

6 2.21 Te Medical Care Plan Beneficiary Registration System Figure 2 Medical Card Security Features Canadian provinces and territories 31 Marc 2003 Province Expiry Date Britis Columbia No No Term Re-registration Alberta No No Birtdate Unique Identifiers Birt date, Signature, and Information on electronic strip - Note 3 Saskatcewan Yes 3 years Birt date and Information on electronic strip- Note 3 Manitoba No No Birt date, Address, and Family members - Note 4 Ontario Yes 5 years Birt date, Signature, Address, Digitized poto, and Information on electronic strip - Note 3 Quebec Yes 4 years Birt date, Signature and Digitized poto NewBrunswick Yes 3 years Birt date and Signature Nova Scotia Yes 4 years Birt date, Signature, and Magnetic strip - Note 5 Prince Edward Island Yes 5 years Birt date and Magnetic strip - Note 5 Newfoundland and Labrador No - Note 1 None None Nunavut Yes 2 years - Note 2 Birt date and Signature Nortwest Territories Yes 2 years Birt date, Signature, and Address Yukon Yes 1 year Birt date, Signature and Address Source: Websites for Medical Care Plans and correspondence wit provincial medical care plan officials. Note 1: Expiry dates on temporary beneficiary cards issued for immigrants or students wit visas and for residents wo require out-of-province coverage for a maximum of 12 monts. Note 2: Beneficiaries re-register every 2 years wit term to be extended to 5 years. Note 3: Te strip allows for te information printed on te front of te card to be read electronically. Note 4: All ealt care cards include te registration number and all te personal ealt care numbers for eac individual family member wo is registered under tat registration number. Note 5: No electronic information is maintained on te strip at te present time. 326 Auditor General of Newfoundland and Labrador

7 2.21 Te Medical Care Plan Beneficiary Registration System As a result of beneficiary cards not aving unique identifiers and expiry dates, and te fact tat te Department as not required reregistration, te Department cannot ensure tat only eligible beneficiaries receive medical services. (b) Number of Cards Te Medical Care Plan maintains a Beneficiary Registration System tat contains information on individuals tat ave been issued a beneficiary card including teir Medical Care Plan beneficiary number, surname, given name, gender, date of birt, and address. Te system classifies te beneficiary numbers as eiter active, inactive or terminated. Eac classification is defined as follows: Active - tere ave been claims for medical service coverage witin te last ten years; Inactive - tere ave been no claims for medical service coverage witin te last ten years; and Terminated - te card as been cancelled for provincial billings; owever, out-of-province billings will still be paid under reciprocal agreements. Figure 3 Figure 3 indicates tat, in December 2002, tere were 984,089 beneficiary numbers recorded in te system. Department of Healt and Community Services Newfoundland Medical Care Plan Beneficiary Numbers December 2002 Status Number of beneficiary numbers Active 562,178 Inactive 50,767 Sub-total 612,945 Terminated 371,144 Total MCP Beneficiary Numbers 984,089 Source: Newfoundland Medical Care Plan Beneficiary Registration System Auditor General of Newfoundland and Labrador 327

8 2.21 Te Medical Care Plan Beneficiary Registration System Te Department makes payments to pysicians based on invoices received wic lists te services tey performed and te related beneficiary number. Tese invoices are compared to information recorded in te Registration System to determine weter te beneficiary number is valid and te individual is classified as an eligible beneficiary. Invoices received for bot active and inactive card numbers will be paid by te Department. As Figure 3 sows, te total number of active and inactive cards as at December 2002 is 612,945. Te population of te Province as of 30 November 2002 as reported by te Newfoundland Statistics Agency was 531,595. Terefore, tere were 81,350 more cards tan residents. Altoug some of te difference may be accounted for by various factors including deceased card olders wose deats ave not been reported to te Department and former residents wo ave left te Province, te Department does not ave te information necessary to determine tis. Because of te weaknesses over te registration of beneficiaries, te weaknesses over te design of beneficiary cards, and not reregistering beneficiaries, it is possible for medical services to be obtained and payments made for te 81,350 beneficiary cards wic are in excess of te Province s population. (c) Inactive Card Payments Figure 3 indicated tat tere were 50,767 inactive beneficiary numbers as at December A process commenced in December 2001 wereby every two weeks a report is produced by te Registration System wic lists te inactive beneficiary numbers for wic claims for payment ave been received. Department staff attempt to contact tese individuals to determine weter tey were eligible beneficiaries and weter te designation of te card sould be canged. From December 2001 to 31 January 2003, 1,016 inactive beneficiaries wit processed claims were contacted by te Department to determine eligibility. Te Department received responses from 636 of te 1,016 beneficiaries. Of te remaining 380 beneficiaries, 82 letters were returned as undeliverable and tere was no response from 298 beneficiaries. As a result, te Department as not determined tat all inactive card payments were made on bealf of eligible beneficiaries. Tese 380 beneficiaries maintain teir inactive status in te Medical Care Plan Beneficiary Registration System. 328 Auditor General of Newfoundland and Labrador

9 2.21 Te Medical Care Plan Beneficiary Registration System (d) Terminated and Invalid Card Payments Figure 3 sows tat, as at December 2002, tere were 371,144 cards tat were designated as terminated in te Registration System. A beneficiary number is terminated if te qualifying criteria of residency and citizensip under te Medical Care Plan are no longer met. Te most common reasons tat a beneficiary number is terminated are te deat of te beneficiary or a move by te beneficiary to anoter province. Oter reasons for te termination of a beneficiary card number include te expiration of temporary beneficiary cards and te issuance of a new beneficiary card upon notification of a cange in name. No payment will be made for in-province medical service carges relating to terminated beneficiary numbers. However, under reciprocal agreements wit oter provinces and territories, te Department is required to pay for all medical services provided by pysicians. Because of te lack of security features on te beneficiary cards, pysicians providing medical services are not able to determine a person s eligibility. As a result, payments are made for medical services relating to all beneficiary cards including terminated and invalid (i.e. number not in Registration System) beneficiary numbers. For te years ended 31 Marc 2003 and 31 Marc 2002, te Department paid out-of-province medical care services totalling $4.6 million and $3.9 million respectively. Of tis, in 2003, $320,000 and in 2002, $318,000 was paid for terminated or invalid beneficiary numbers. As a result, te Department is paying for medical services for ineligible beneficiaries because it is required to do so under reciprocal billing arrangements. Tis igligts te need for te Department to institute stronger controls over its cards by te use of expiry dates, unique identifiers and requiring periodic re-registration. Te reciprocal billings received from oter provinces include beneficiary numbers. Eac mont, te Department produces two reports relating to beneficiaries wo are included in reciprocal billings. One of te reports produced lists all beneficiary numbers wic ave ad out-of-province services reimbursed in 8 or more of te previous 15 monts. Te May 2002 report contained 315 beneficiary names. Te oter report produced lists beneficiary numbers, designated as eiter terminated or invalid in te Registration System, wic ave ad out-of-province services Auditor General of Newfoundland and Labrador 329

10 2.21 Te Medical Care Plan Beneficiary Registration System reimbursed during te previous mont. Te May 2002 report contained 48 beneficiary names. All beneficiaries identified in tese two reports are required to be contacted to determine eligibility; owever, as of February 2003, te Department is still attempting to contact beneficiaries listed in te May 2002 reports. Terefore, no work as started on te reports generated from June 2002 to February As a result, te Department is not adequately investigating wy payments are made for out-of-province medical services for individuals wo are not eligible for coverage under te Province s Medical Care Plan. In addition to reviewing te Department s reports, we selected 40 beneficiary numbers tat were designated as terminated due to te deat of te beneficiary to determine weter tese numbers were terminated on a timely basis after deat. Our review indicated tat 26 of te 40 beneficiary numbers were not terminated in te System until twelve or more monts after te date of deat of te beneficiary. Two of te 26 numbers were not terminated until over 14 years after te date of deat of te beneficiary. (e) Terminations Due to Issuance of New Beneficiary Cards In certain circumstances, suc as on notification of a cange in name, te Department will issue a new beneficiary card containing a beneficiary number different from te one on te original card. Wen te second card is issued, te Department s policy is to designate te beneficiary number on te original card as terminated. Our review indicated tat wen new cards are issued to beneficiaries in tese circumstances, te original beneficiary numbers are not always designated in te Registration System as aving been terminated. In January 2002, te Department produced a report wic identified instances were one or more beneficiary numbers ad similar identifiers suc as name, address or birt date. Based on te Department s review of tis report, 662 beneficiary numbers were terminated. Department officials indicated; owever, tat teir review of te January 2002 report was still in progress and tat no furter reports of tis type ave been produced. 330 Auditor General of Newfoundland and Labrador

11 2.21 Te Medical Care Plan Beneficiary Registration System We identified 204 instances as at December 2002 were tere was more tan one beneficiary number in te Registration System aving te same name and birt date information. None of tese beneficiary numbers ad been designated as terminated. Te presence of more tan one number for tese beneficiaries could result in payments being made for medical services on bealf of ineligible beneficiaries. Recommendations Te Department sould: strengten controls over te registration process by requiring applicants to provide original documents and by validating birt information on applications wit provincial vital statistics registries; improve te security features of te beneficiary card to include suc design features as a picture and an expiry date; require beneficiaries to re-register witin a fixed time interval; and increase its efforts to follow-up on te monitoring reports it produces. Department s Response Strengten controls over te registration process by requiring applicants to provide original documents and by validating birt information on applications wit provincial vital statistics registries. Wile MCP recognizes te potential for potocopies of original documents to be altered or falsified, tere as never been any indication tat tis is indeed appening. Te following explains wy te decision was made to accept potocopies: Clients in te St. Jon s and Grand Falls-Windsor areas can visit our offices in person and present original documents to be potocopied by our staff. Tese original documents are immediately returned to te client. All oter clients ave to send teir original documents troug te mail. Tis would include documents suc as Birt Certificates, Passports, SIN cards, Federal Government ID s, Permanent Resident cards, and Auditor General of Newfoundland and Labrador 331

12 2.21 Te Medical Care Plan Beneficiary Registration System Immigration papers. Tese are not documents tat anyone would want to ave lost in te mail as tey could be costly to replace. It is very convenient for clients to copy teir original documents and submit te copies wit teir applications. If for some reason tey are never received by MCP, te client can simply take anoter copy and submit it again. If original documents were received by MCP and for some reason did not get returned to te client, te Department would most likely ave to cover te replacement cost. If clients are in te St. Jon s, Clarenville, Gander, Grand Falls- Windsor or Corner Brook areas, Birt Certificates are available at te Government Service Centers. Anyone outside tese areas would ave to apply troug te mail, a process wic could take 6-8 weeks or longer. Tis could be very stressful to a person wo was being told tey need tis particular document to get teir MCP card. Many times tey are also being pressured for a valid MCP number by a pysician s office in order to receive treatment. I would also like to point out tat wit te implementation of te UPI/Client Registry, regular deat reports are now being received by MCP. Tis will provide te Department wit te necessary information to terminate eligibility of residents as tey become deceased. If MCP were to validate birt information wit provincial vital statistics registries, te cooperation of te Vital Statistics Division would be necessary. Wile we recognize te potential to register newborns wit invalid information, we ave ad no evidence or indication tat tis is appening. Tere are many different scenarios surrounding te birt of a cild tat could create confusion if MCP was to try to validate its information against Vital Statistics, suc as: Wen te birt of a newborn is recorded, te information generally sows te cild s sex and date of birt and te moter s name. Quite often te moter may not ave taken te fater s surname but will want te cild to use te fater s surname or even a combination of bot surnames. If we were to ceck wit Vital Statistics in a case like tis, it would be difficult, if not impossible, to matc. 332 Auditor General of Newfoundland and Labrador

13 2.21 Te Medical Care Plan Beneficiary Registration System To insist on a birt certificate for eac newborn would bring its own problems as mentioned previously. Attempting to validate newborns wit Vital Statistics would in all likeliood see an increase in data quality issues. Improve te security features of te beneficiary card to include features suc as a picture and an expiry date. In 1999 MCP performed a study related to tis issue and it was determined tat a one-time registration of te residents of te Province would cost between $975,000 and $1,210,000. It was estimated tat te annual cost of providing tree year renewals would be in te range of $436,000 to $526,000. Due to budgetary pressures, te Department as not been able to identify a source of funds. It will ave furter discussions wit Treasury Board officials as part of te 2004/05 budget process. Require beneficiaries to re-register witin a fixed time interval. Wen compared to oter jurisdictions, te volume of MCP numbers existing in te database over and above our population is quite good. For example, in Britis Columbia tey typically average 20% extra provincial ealt numbers in teir registration system. MCP currently as approximately 15%. Due to te ongoing efforts of te Department tis number is continually decreasing. A policy and process will be developed wic will require beneficiaries to re-register witin a fixed time interval. Increase efforts to follow-up on monitoring reports produced. We will increase our efforts to do more timely follow-up and monitoring of reports produced by te MCP Beneficiary Registration System in an effort to identify ineligible beneficiaries. Auditor General of Newfoundland and Labrador 333

14 2.21 Te Medical Care Plan Beneficiary Registration System 334 Auditor General of Newfoundland and Labrador