DATE OF ISSUE: 5 NOVEMBER 1997
INCOME SUPPORT QUALITY ASSURANCE PROGRAM IMPLEMENTATION OF STAGE TWO BUSINESS PROTOCOLS
Purpose
The purpose of this Departmental Instruction (DI) is to formalise the implementation of Stage Two of the Income Support Quality Assurance (QA) Program and to define the roles and responsibilities of Income Support Staff in undertaking their QA activities as defined in the Stage Two - Business Protocols.
Background
2.Stage One of the QA Program commenced in January 1997, and involved the introduction of a Data Integrity Business Protocol, addressing QA activities in relation to the current two officer processing and Responsibility Based Processing (RBP) environment. (Please refer to Departmental Instruction No C26/97 (issued in April 1997) for further information on Stage One of the QA Program).
3.Stage Two of the QA Program involves the introduction of three Business Protocols addressing Data Integrity, Decision Analysis and Fraud Control. As each State Office commences processing in a single officer processing or Single Point of Contact (SPOC) environment the Stage One Business Protocols are replaced by the Stage Two Business Protocols. (The Stage Two Business Protocols dated May 1997 were issued to New South Wales and Tasmania State Offices at that time. They will be issued to each State Office as they commence SPOC processing.)
4.SPOC processing commenced in NSW and TAS State Offices late in May 1997 and is expected to be introduced in all State Offices by the end of 1997.
Objective of the Quality Assurance Program
5.The objective of the QA Program is to improve the level of service delivery to veterans and their dependants. Implementation of checking procedures, as instructed in the protocols, will ensure that veterans and their dependants are receiving the correct rate of pension and that the decisions made in Income Support are correct and consistent throughout Australia.
6.The procedures identified in the protocols will also serve as effective tools in identifying best practice, training needs and areas requiring improvement.
7.The purpose of these Protocols is to record the results from checks to ensure that Data Integrity, Decision Analysis and Fraud Control are being upheld. Analysis of these results will provide an overview of how each State is performing in relation to:
- reduction in error rate and correctness of decision - for Data Integrity (Decision Integrity);
- deterrence of the incidence of internal fraud - for Fraud Control; and
- correctness and consistency of decision making for Decision Analysis.
8.The Stage Two protocols are also aimed at:
- meeting audit requirements;
- gaining an assurance that a large percentage of cases are correct and accurate; and
- providing State Offices with a consistent approach to undertaking QA checks.
Legislative Requirements
9.Finance Direction 1A intimates that adequate system controls, accounting procedures and effective deterrent measures must be in place in an environment where single officer processing is adopted. We must therefore ensure that our systems and processes provide efficient and effective controls which are able to withstand any external scrutiny.
10.In addition, as the Income Support payments come under Finance Regulation 45A (5) (b) (ii) there is a requirement for the adequacy of these system controls and account procedures to be formally approved by the delegate of the Minister of Finance, in this case the Division Head, Compensation and Support Division.
11.Given the above legislative requirements Fraud Control, Decision Analysis and Data Integrity procedures are a mandatory requirement in a SPOC environment.
Income Support Quality Assurance Program - Stage Two Business Protocols
12.There are three components of the Stage Two Income Support QA Business Protocols which address:
- Fraud Control;
- Data Integrity; and
- Decision Analysis.
An overview of each Protocol is provided in this DI - however it is important that the Stage Two Business Protocols are read and referred to for complete and comprehensive administrative and procedural information relating to the QA Program.
Fraud Control Protocol
Overview
13.With the introduction of processing Income Support casework within a SPOC environment there is an increased potential for internal fraudulent activity to occur. To enable us to counter this increased risk, a number of Fraud Control procedures, predominantly involving physical checks of documents, have been developed to address these concerns by minimising the chances of fraud occurring or remaining undetected.
14.The Fraud Control Protocol has been designed to provide all stakeholders with a satisfactory level of confidence that any fraudulent claims are being identified and acted upon in a timely and appropriate manner.
15.The application and adherence to the procedures outlined in the Fraud Control Protocol is a mandatory requirement for all State Offices.
Methodology
Team Leader's Role
16.The Team Leader is required to sight and verify a claimant's original Proof of Identity (POI) and service documentation as being authentic as soon as possible, but within one month of the case being finalised. This control is a necessary in line process as a means of deterring and detecting any incidence of internal fraud. In instances where a Team Leader is the decision maker then another Team Leader must check and verify the POI and service documentation.
17.In the absence of the Team Leader's check, the only control would be that of the Quality Assurance Officer's (QAO) check. The QAO check is an important step in the process, providing assurances that the Team Leader's check is being undertaken on all cases submitted for payment of a Service Pension and/or allowance.
Quality Assurance Officer's (QAO) Role
18.As part of the Fraud Control procedures, the role of the QAO is to ensure that the Team Leader has adequately performed their control check. A further role of the QAO is to undertake a series of on file checks to verify that POI and service documentation integral to the claim process is provided and they are satisfied that they appear genuine.
Cases Selected for QA Checking
19.All finalised CMS cases granted Service Pension where no other eligibility for payment exists, are to be checked for Fraud Control purposes by both the Team Leader and QAO.
20.A listing of cases identified as requiring checking by both the Team Leader and QAO for Fraud Control purposes will initially be forwarded to the QAO on the first working day of each week, listing cases processed during the previous week.
21.Programming changes are being undertaken to enable the identification of cases to be checked through the Adhoc Information System (AIS). QAO's will be able to submit an AIS query at the beginning of each week to identify the cases processed during the previous week. Advice of the parameters required to extract this information from the AIS will be forwarded to each QAO once programming has been completed.
The Data Integrity Protocol
Overview
22.The purpose of the controls and procedures detailed in the Data Integrity Protocol is to provide a sufficient level of confidence to stakeholders that all data and decision making procedures for granting and updating claims are accurate and complete. While the Data Integrity Protocol is designed to protect the integrity of the data keyed onto the system from the veteran's file, the correctness of the decision is an important by-product of the data integrity process. Therefore, separate sections for Data Integrity and Decision Integrity containing the items for checking and performance standards are provided in this Protocol.
Methodology
Income Support Processing Types - Categories for Selection
23.All finalised Income Support processing type cases will form the population to be selected on a monthly basis, and they have been grouped into two categories as follows:
- reviews - both pensioner and departmental initiated; and
- other - new claims, interstate transfers, Income Support Supplement, Commonwealth Seniors Health Card, Qualifying Service determinations only, manual cases, Department of Social Security new claims, bereavement and debt control/overpayment activity.
Items to be Checked
24.The Data Integrity Protocol of the Stage Two Business Protocols (May 1997) provides details of the items to be checked by the QAO, when undertaking a Data Integrity check. The 'Items to be Checked' were developed based on the fields from each PIPS screen accessed when undertaking the various IS processing activities.
25.A report, providing details of those cases selected for a QA check will be automatically generated in each State Office on the first working day of each month, from cases processed during the previous month.
Decision Analysis Protocol
26.The Decision Analysis Protocol is currently being developed by the National Office Quality Assurance Co-ordinator (NQAC). The Decision Analysis Protocol will complete the package of Business Protocols. It is envisaged that this Protocol will introduce a systematic approach to decision analysis activity by focusing on those areas where preliminary analysis has indicated that there may be a problem of some sort or another in the decision making process.
Role of the Team Leader
Recording Data Integrity and Fraud Control QA Checks
Individual File Notes on Cases Selected for QA Checking
27.The QAO in each State is required to record the results of their Fraud Control and Data Integrity QA checks undertaken on the cases selected. All cases checked must have a file note placed on the file advising of the check undertaken. In Part 5 - Attachment A of the Protocol, is an example of what should be attached to each individuals case file, identifying the type of check, along with the checking officer's name.
Itemised Checklists for Recording QA Results
28.It is a mandatory requirement that QAO's use the Fraud Control and Data Integrity checklists which are provided at Part 5 of the Business Protocol. This is to ensure that all States check on equivalent content. A copy of the checklists may be attached to the individual file however, the original should be stored collectively with other checklists for reporting purposes and as an aid to follow up of results.
29.It should be noted that in any instance where there is a suspicion of fraudulent activity - special requirements do apply and separate action of a more discrete nature is required. Please refer to the Fraud Control Protocol for more comprehensive information on reporting requirements for suspected internal fraud cases.
Reporting the Results of the Data Integrity and Fraud Control QA Checks
30.It is suggested that the QAO report on a monthly basis to their Manager at the State level on the results of the checks. The procedures for reporting at this level is a discretionary State Office decision. However, if a problem has been identified by the QAO which is not being addressed the QAO should report the problem to the next level of management.
31.In addition, monthly reports should be compiled by the QAO and provided to the National QA Co-ordinator (NQAC). The current NQAC is Gill Meager who can be contacted on phone (06) 289 6654.
32.Departmental Instruction - C26/97 issued in April 1997 contained details on the roles of the NQAC and each State's QAO.
33.At Part 5 - Attachment E of the Protocol is an instruction sheet and proforma detailing the information to be provided in the Monthly Report to the National QA Co-ordinator by each State's QAO when reporting their Data Integrity results.
34.When reporting Fraud Control results the QAO's report should cover the cases finalised in the month preceding the month in which they have to be checked and reported upon for Fraud Control purposes. There is no specific reporting proforma for Fraud Control results, however there is a requirement to provide certain information which includes the number of cases selected, errors found and action taken. The distribution list and content of the report will vary depending on the content of the report. (Please refer to Part 2 of the Protocol for further information on Reporting Suspected or Detected Internal Fraud cases.)
National Office Quality Assurance Contact Officers
35.Please contact Martin Dibb on phone: (06) 289 6751, LAN ID: C-C-BD-02 or Gill Meager on phone: (06) 289 6654, if you should require any further information regarding the Income Support QA Program.
RJ HAY
BRANCH HEAD
INCOME SUPPORT
November 1997