QUÉBEC, Nov. 27, 2015 /CNW Telbec/ - Today, Ms. Guylaine Leclerc makes public the report entitled Value-for-Money Audit (Fall 2015). In Chapter 3, she makes known the results from her work at the Régie de l'assurance maladie du Québec (RAMQ).
The RAMQ does not sufficiently take into account the risks of error or fraud in relation to physician compensation, even though it represents 62% of its program expenditures. This has consequences on the organization's culture and, therefore, on all the control mechanisms and the effectiveness and performance assessment measures.
The RAMQ does not apply all the necessary a posteriori controls, which does not allow it to obtain reasonable assurance that the compensation paid to physicians is in accordance with the agreements. The RAMQ also performs a priori controls, mainly of a computer-related nature, to verify the information recorded on claims for payment in accordance with the terms of the agreements. However, these a priori controls alone are not sufficient to ensure the compliance of payments, mainly because they do not make it possible to assess whether the procedure billed corresponds to the services provided.
The different administrative units involved in the a posteriori control process do not receive guidance so as to ensure that they intervene in a structured and complimentary way in order to maximize the effectiveness of their interventions. The RAMQ has not clearly determined the risks related to compensation, the necessary controls in that regard or the responsibilities of stakeholders who carry out these controls.
The billing analysis process is not fully effective. The files with the greatest risk of non-compliance with the compensation agreements are not necessarily selected.
The scope of a posteriori controls is too restricted, which does not allow the RAMQ to obtain the necessary assurance that the compensation paid to physicians is in accordance with the agreements for all compensation methods. Few or no a posteriori controls are performed for certain compensation methods and certain incentives. In 2014, out of 17,542 physicians, 2% were the subject of a billing analysis, generally for a single procedural code.
The effectiveness and performance assessment measures put in place by the RAMQ do not cover the control carried out with regard to physician compensation. In addition, the benchmarking that it performed requires improvements.
The Highlights are available at www.vgq.qc.ca. The full report is available only in French.
Lucie Roy, Director
SOURCE Vérificateur Général du Québec
For further information: Lucie Roy, Director, Cabinet, communications et affaires stratégiques, Auditor General of Québec, Tel.: 418 691-5915