24.09.08-9.1 Report on the Audit of Ophthalmic Claims

APCSA Board: 24 September 2008:

Agenda Item 9.1

/
Report on the Audit of Ophthalmic Claims

1 Purpose

This paper is to inform PCTs of the results of the audit of ophthalmic claims from March to September 2008

2 Background

The Avon Audit Consortium Internal Audit Report dated 20 January 2004 recommended the introduction of a system to monitor payments to opticians. Recommendations also outlined the need for fully documented procedures in respect of this. Avon Primary Care Support Agency (PCSA) and the Avon Local Counter Fraud Specialist Unit (LCFSU) wrote such procedures and presented them to the PCSA Board. Unfortunately there were delays in this process due the PCSA Board not being quorate in August and the meeting being cancelled for the same reason in September. The PCSA Board approved these procedures on 10 November 2004, with an implementation date of 1 December 2004. The PCSA Board review these procedures on an annual basis.

3 Post Payment Verification of Ophthalmic Claims

Procedures state that an audit of all practices should be made over a two-year period, checking on average 5 practices per month. 2.5% of claims submitted by the practice are verified.

March 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 89 / 3 / 2 / 1
Bristol (Practice 2) / 8 / 1 / 1
South Gloucestershire / 70 / 1 / 1
North Somerset / 225 / 2 / 1 / 1
Bath & North East Somerset / 319 / 1 / 1

April 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 17 / 1 / 1
Bristol (Practice 2) / 33 / 1 / 1
South Gloucestershire / 31 / 1 / 1
North Somerset / 22 / 1 / 1
Bath & North East Somerset / 28 / 1 / 1

May 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 240 / 1 / 1
Bristol (Practice 2) / 38 / 1 / 1
South Gloucestershire / 119 / 3 / 1 / 2
North Somerset / 173 / 1 / 1
Bath & North East Somerset / 149 / 1 / 1

June 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 31 / 1 / 1
Bristol (Practice 2) / 30 / 1 / 1
South Gloucestershire / 25 / 1 / 1
North Somerset / 39 / 1 / 1
Bath & North East Somerset / 18 / 1 / 1

July 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 39 / 1 / 1
Bristol (Practice 2) / 40 / 1 / 1
South Gloucestershire / 64 / 2 / 2
North Somerset / 51 / 2 / 2
Bath & North East Somerset / 16 / 1 / 1

August 2008 Payment

/ No. of claims submitted by practice / No of claims selected for verification / Confirmed Service Provided / Still awaiting reply / Confirmed Service not provided – referred to LCFS / Non-responder – referred to LCFS
Bristol (Practice 1) / 35 / 1 / 1
Bristol (Practice 2) / 2 / 1 / 1
South Gloucestershire / 35 / 1 / 1
North Somerset / 34 / 1 / 1
Bath & North East Somerset / 12 / 1 / 1

4 Patient Eligibility to free sight tests and vouchers

Under GOS certain groups of patients are entitled to free NHS sight test (the criteria is different for vouchers and again different for repairs). These relate to a patient

who is under the age of 16 years;
who is under the age of 19 years and receiving qualifying full-time education;
who is aged 60 years or more;
whose resources are treated in accordance as being less than, or equal to, his requirements;
who requires to wear a complex appliance;
who is registered blind or partially sighted under section 29 of the National Assistance Act 1948;
who has been diagnosed as suffering from diabetes or glaucoma, or has been advised by an ophthalmologist that he is predisposed to the development of glaucoma;
who is aged 40 or over and is the parent, brother, sister or child of a person who has been diagnosed as suffering from glaucoma; or
who is a prisoner.

Optometrists should check evidence that the patient is eligible to the free NHS service and mark on the form that evidence has been seen to verify this. Each year PCSA receives an estimated 31,000 claims where evidence has not been seen.

Procedures state that 64 claims will be investigated each month (representing 2.5% of those claims where evidence has not been seen). Patients should be asked to give evidence that they were entitled to the free or subsidised service or asked to pay the appropriate charge. Those patient groups shown in italics above will not be checked as this is based on the optometrists own clinical judgement or would require access to patient medical records.

March 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 4 / 3 / 1
Those over 60
Recipients of some tax credits / 16 / 9 / 1 x £19.32 / 6 / £19.32
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 44 / 32 / 1 x £19.32 / 11 / £19.32

April 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 9 / 8 / 1
Those aged over 60
Recipients of some tax credits / 26 / 21 / 1 x £34.60 / 4 / £34.60
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 29 / 22 / 7

May 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 17 / 14 / 3
Those aged over 60
Recipients of some tax credits / 20 / 13 / 2 x £19.32
£19.32 / 5 / £38.64
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 27 / 19 / 1 x £19.32 / 7 / £19.32

June 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 5 / 2 / 3
Those aged over 60
Recipients of some tax credits / 23 / 15 / 8
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 36 / 13 / 1 x £58.20 / 22 / £58.20

July 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 3 / 1 / 2
Those aged over 60
Recipients of some tax credits / 17 / 15 / 2
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 44 / 20 / 24

August 2008 Payment

/ From 64 selected, no in this group / Evidence Provided / Appropriate Fee recovered / Still awaiting reply / Non-responder or no evidence provided – referred to LCFS / Total fees re-covered
Children under 16
Full time students under 19 / 5 / 3 / 2
Those aged over 60
Recipients of some tax credits / 22 / 16 / 6
Recipients of some income based allowances (those patients will be in receipt of form HC2) / 37 / 17 / 20

5 Local Counter Fraud Specialist

PCSA have informed LCFS when performance indicators are available each month. In addition to this 89 cases where the patient has not responded have been referred to them. There have been no cases referred where the patient has indicated that the service was not provided.

6 Recovery of Fees

During this period a total of £189.40 has been recovered.

7 Recommendations

Board members are asked to note the content of this paper and circulate to appropriate colleagues within their respective organisations.

Julie Cooper

General Manager

Avon Primary Care Support Agency

15 September 2008

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