HC has awarded a contract to a private sector corporation, ESC, to process and adjudicate claims by providers of pharmaceuticals, dental services and medical supplies and equipment to eligible clients. The processing and adjudication of claims were previously being done by First Canadian Health (FCH). After expiry of the FCH contract, the new contractor, ESC Canada, began operations and claims processing activities in December 2009.
The department seeks assurance that the contractor is undertaking the payment of these claims in adherence to departmental and governmental standards and that the payment errors do not exceed the defined maxima. In response to recommendations from the Office of the Auditor General, HC commissioned a study by Sussex Circle to develop a cost-effective strategy to measure the errors in the payments by the contractors. The recommendations from this study include determining the error rates by conducting an independent assessment of a sample of transactions periodically, which will be based on the controls at ESC and HC.
The project was initiated to determine the error rate for these payments, establish the error rate and establish an action plan, should the error rate be above the tolerable level according to HC.
The objective is to award a contract for two (2) resources (Project Manager/Leader x 1, Senior Auditor x1) tto carry out the procedures described in the error rate measurement frameworks and to report on the results of the procedures without any expression of opinion to help HC to determine the error rates of Health Benefits payments by Express Scripts Canada (ESC).
