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Health

Health

 

Summary

Matters from the current audit

Healthcare card processes—see below

Processes to check receipt of services for which physicians billed—see page 101

ALBERTA HEALTH SERVICES

Matters from the current audit

Disaster recovery planning—see page 103

Matters from prior audits

Health—Alberta Health Services—Managing healthcare waste materials follow-up—see page 51

AHS has implemented the following prior year recommendations:

  • Financial operations—see page 106
  • Effectiveness of insurance reciprocal (Liability and Property Insurance Plan)—see page 107
  • Payroll—accuracy monitoring activities—see page 107

In the past year AHS made satisfactory progress on:

  • Approval of drug purchases—see page 108

Findings and Recommendations

Matters from the current audit

Healthcare card processes

Background

The Alberta Health Care Insurance Act requires the Minister of Health “in accordance with this Act and the regulations… to provide benefits for basic health services to all residents of Alberta.” The Department of Health provides access to these benefits by issuing, to each eligible resident, a paper healthcare card which indicates the individual’s unique lifetime personal health number. As a prerequisite for obtaining the card, individuals must provide proof of their identity, Alberta residency and legal right to be in Canada.

In previous recommendations we focused on the processes to obtain an Alberta healthcare card and the department’s controls over issuing duplicate cards. We focus here on strengthening the department’s process to ensure that Alberta Health Care Insurance Plan (AHCIP) registrants continue to meet the residency requirements.

Under the Alberta Health Care Insurance Act, a resident is defined as “a person lawfully entitled to be or remain in Canada, who makes the person’s home and is ordinarily present in Alberta and any other person deemed by the regulations to be a resident, but does not include a tourist, transient or visitor to Alberta.”

The department is responsible for ensuring that registrants continue to meet the residency requirements.

The department uses the following processes to check whether registrants continue to be residents of Alberta:

  • The department gets migration reports from most provinces and territories about people who have registered with other provincial and territorial health care systems, and from Alberta Vital Statistics if a person dies in Alberta. When the department gets this information, it cancels the person’s Alberta healthcare coverage and records the AHC number as ineligible.
  • The department can also get information on address changes for individuals with AHC numbers if they are registered for other benefits for which the department pays. When individuals change their address, including leaving Alberta temporarily for a period expected to exceed six months, they are supposed to contact the department.
  • The department receives and investigates tips from residents, leading in some cases to the cancellation of Alberta health coverage for ineligible registrants. In some cases, Service Alberta’s Special Investigations Unit (SIU) conducts the investigation if it is suspected that there is fraudulent provision of insured health services due to inappropriate use of AHC numbers.

The department has staff who identify and assess the risks of the department making payments for amounts not in compliance with legislation. This includes the risk of the department paying for healthcare coverage of individuals who do not meet the residency requirements. During 2014–2015, through a tip, the department identified a type of individual profile that presented a higher risk for ineligible residency status. They checked a sample to determine whether individuals with this type of profile still met the residency requirements. Through this test they identified some ineligible registrants and cancelled their registration. As a result of validating the risk profile, the department is currently considering the next steps to manage this risk.

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