Veterans' Affairs Processing (VAP) quality checking 111-22190000

The objective of the quality checking procedure is to:

• give checkers the tools to be able to identify strengths and weaknesses in the Veterans’ Affairs Processing (VAP) business process, highlighting opportunities for continuous business improvement, using effective quality checking processes
• make sure quality checkers have the same understanding of the process
• ensure quality checkers are completing the checks in a consistent manner, by documenting the quality checking process

Claims can be submitted:

• manually using paperwork completed by the service provider
• online by claiming software embedded into the practice/patient/pharmacy management software (PMS), or
• via DVA Webclaim accessed through Services Australia Health Professional Online Services (HPOS)

VAP has 3 types of claims:

• allied health (which includes community nursing & nursing home)
• hospital, and
• medical

Allied health, medical and hospital claims are subject to quality checking.

The Report Management and Distribution System (RMDS) is used to identify VAP claims for quality checking. All channels are subject to quality checks.

Team Leaders are responsible for making sure:

• quality checking is performed on a daily basis for every processing day available on RMDS
• checkers have completed the appropriate training
• quality checks are undertaken as outlined in this procedure
• results of quality checks are recorded appropriately
• issues are addressed and corrections are made immediately (refer to Feedback)

Quality checkers must make sure that:

• VAP business rules have been applied correctly
• quality checking is performed on the specified sample size
• feedback is given to the Service Officer and advice provided to the Service Officer’s team leader (see Correction of errors)
• quality checking results are recorded and reported using the VAP Quality Reporting form

Quality checking of own work

Quality checkers must not quality check their own work. If their own work is selected, it must be given to another staff member who has been accredited to conduct quality checks.

Staff members selected to undertake quality checking must:

• successfully complete the VAP Quality Checker training - MPL00082 - VAP QC Checker, see the Training & Support page for the link
• have knowledge of relevant and current policies and procedures and know where to find them

Pre-checks

New Starters

New starters will have 100 per cent of their work checked on the day the work is performed until considered proficient in processing. The Proficiency Documents are held and maintained by Operational Planning Health (OPH), in conjunction with the Program area.

Post-checks

Post-checks (covered in this procedure) involve checking a statistically valid, random selection of work processed the previous day. The results are reported as accuracy of processing for VAP.

Targeted checks

In addition to the pre and post-checks, targeted checks provide an opportunity to look at other areas of the process which are not part of pre and post-checking. Targeted checks can currently only be performed on manual work completed from PaNDA.

Targeted checks for VAP may be:

• checks on staff members with identified quality issues
• Aim for Accuracy (separate procedure)
• checks on newly-proficient Staff

Post-checks

The quality checks to be completed for VAP are set at 2% of the previous day’s processed work.

VAP post-check parameters

Quality checking must:

• be conducted on 100% of Service Officer assessed services in the selected claim
• not be conducted on auto-operator assessed services, examples of auto-operator numbers:
• 22221
• 33332
• 55554
• 77776
• 88887
• 99998

Quality checking on services rejected with a 609 Reason code - Service cancelled at providers request

If a claim is presented that has been rejected/deleted with a 609 reason code, the Quality Checker is to search PaNDA to see if any paperwork has been received. If there is, QC the claim against the paperwork. If no paperwork has been received:

• it is assumed the request was received during a phone call, and
• no QC is to be performed on the claim

The quality check sample count is not based on date of service. Quality checkers must count the sample as follows:

• The header error is counted as +1. Note: the header is not counted for online claims or those submitted via DVA Webclaim
• Each patient in the claim is counted as +1 regardless of how many dates of service are being claimed or how many errors are found

For manual claims, count the number of patients on the VPSI screen, then add any 376 patient rejections noted on the paperwork.

For online and DVA Webclaim, the number of patients must be determined by counting the number of patients transmitted on the VQME screen or by keying 'f' in the 'S' field on the VQRF screen.

See the Resources page for several examples.

Time frames

If quality checking is not performed for a particular day, the work must be checked within 2 working days.

Note: quality checks must be completed by close of business of the first working day of the new month.

Resources

Quality checkers must have access to:

• mainframe, including the VAP systems and the Report Management and Distribution System (RMDS) reports
• Operational Blueprint
• source documentation
• claims (including DVA Webclaim) include:
• text (indicated by a 'T', ‘B' or 'O' in the service line on the history screen)
• VQME (raw data for VAP claims)
• Processing and National Demand Allocation (PaNDA)

Each time a quality check is completed, the Quality Checker must enter the information on the VAP Quality reporting form, and provide feedback to the Service Officer and their Team Leader advising them of the outcome via the VAP Quality Checking Performed email template. This feedback should:

• be positive for transactions identified as error-free
• be given the same day or as soon as possible after the quality check is completed
• describe the error identified, and what was incorrect
• explain the action that should be taken to correct the error
• include any relevant reference material that supports the action, such as Operational Blueprint details if available

If errors are identified, Service Officers must:

• be given feedback in the form of the QC email template. For example, history to be adjusted, escalation to the appropriate areas where necessary
• take appropriate action to correct the error(s)

If the Service Officer does not have the required knowledge to action the correction, they can seek it through their LPS.

Any enquires regarding quality checking feedback should be directed to the Service Officer’s Team Leader. If they support the dispute, all details will need to be forwarded to the Provider Engagement Team with VAP QC Dispute in the subject line. See the Resources page, Health Service Delivery Division, for the email address.

The VAP Program area will check the validity of the QC Error and provide a decision on whether the dispute will be upheld. Details will also be shared with the Quality Team for reporting purposes. See Quality checking dispute process for Health Service Delivery Division.

Quality checkers:

• must follow the appropriate escalation process for the relevant programme
• requiring clarification on processing business rules should follow the appropriate escalation process for the relevant programme

Quality, Performance Operations & Technical Support is only responsible for the management of the quality checking procedures.

Error categories

VAP quality checking error status codes are broken into 3 categories:

• error free status code (no error)
• document error status codes
• processing error status codes

Definition of critical and non-critical errors

VAP error codes are categorised as critical and non-critical.

An error is defined as critical when there is a potential risk to the:

• process affecting payments and/or information to Services Australia - Medicare Program and its customers
• reputation of Services Australia

An error is defined as non-critical when there is no identifiable risk to the business process (payment and/or registration) and will not impact on the reputation of Services Australia.

Note: while non-critical errors are recorded as part of the quality checking process, they do not impact the quality checking results reported to stakeholders (only critical errors are used to calculate the accuracy of processing results).

See the Resources page for lists of error codes.

Results of quality checks for the program are recorded and reported using the VAP Quality reporting form. This data is used to report accuracy of processing results to the Department of Veterans' Affairs.

All post-check results for the month must be completed and submitted by close of business of the first working day of each new month.

Method for managing and storing feedback

VAP Operations have a Feedback and Reporting Tools register where issues are recorded and used for reporting.

Analysis of errors is the responsibility of the program. Underlying factors (reasons) for errors are identified by the Team Leader and/or the Service Officer if required.

The VAP program is responsible for ongoing analysis on systemic errors.

Quality checking procedures are regularly reviewed and updated by the program, in consultation with the Quality, Performance and Technical Support team. The review ensures that the error codes are current and applicable, and that approved changes to program business policies and procedures are included.

Any changes needing immediate action will be updated accordingly. Changes that are not critical to quality will be included in the review of the procedure.