Avon Primary Care Support Agency
Procedures for the Audit of Ophthalmic Payments
Avon Primary Care Support Agency
Document status: Final
Version / Date / Comments
1.0 / 01.09.04 / Pending Board approval
1.1 / 10.11.04 / Board approval
1.2 / 01.10.05 / Amendments added pending review by PCSA Board
1.3 / 12.10.05 / Board approval
1.4 / 01.03.06 / Amended to state that over 65’s would not be contacted pending Board approval
1.5 / 22.03.06 / Board approval
1.6 / 22.12.06 / Amendments made pending review by PCSA Board

Julie Cooper General Manager

If you need this document in a different format please telephone Helen Bond on 0117 9002559

Contents

1Background………………..…………………………………………………………. 1

2Post Payment Verification of Ophthalmic Claims…………………….. ……….1

3 Patient Eligibility to free sight tests and vouchers………..……………………2

4Comparison of Performance Indicators………………………………………… 3

5Comparison of Individual Claim Types…………………………………………..3

6The requirement for an Ophthalmic Advisor.………………………………….. 3

7LCFSU action to be taken with regard to Optometrists…………….…..…….4

8 Review of these procedures…………………………………..…………………..4

Audit of Services provided by an Optician - OPCHECK1 (a)…………………5

OPCHECK1 (b)……………………………………………………………….. ……....6

OPCHECK1 (c)……………………………………………………………………….. 7

OPCHECK1 (d)………………………………………………………………………..8

OPCHECK1 (e)…………………………………….…………………………………..9

OPCHECK2 (a)………………………………………………………………….. 10/11

OPCHECK2 (b)………………………………………………………………….. 12/13

OPCHECK2 (c)……………………………………………………………………14/15

OPCHECK3…………………………………………………………………………..16

LCFSU1………………………………………………………………………………. 17

LCFSU2………………………………………………………………………………. 18

LCFSU4………………………………………………………………………………..19

LCFSU5………………………………………………………………………...20/21/22

Contents

1Background

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) have written this policy jointly. This procedure document outlines the different areas that will be audited, how, by whom and with what frequency.

There are 127 practices within the former county of Avon. PCSA is responsible for authorisation and payment of claims from these optometrists on behalf of Bristol North, Bristol South & West, North Somerset, South Gloucestershire and Bath & North East Somerset PCTs.

Under General Ophthalmic Services (GOS) certain groups of patients are entitled to free NHS sight tests (for example patients under 16, recipients of Working Family Tax Credit etc). Many of these patients are also entitled to receive help towards the cost of purchasing or repairing spectacles (or purchasing contact lenses). Department of Health ‘GOS’ forms are used by each optician to claim payment from their PCT.

Approximately 275,000 claims were processed during 2005/6, the majority being sight tests (203,000). Each Optometrists practice has a unique practice number and PCSA enter claims on the ‘Exeter’ Ophthalmic payment system against these numbers.

2Post Payment Verification of Ophthalmic Claims

The PCSA Board agreed on 24 March 2004 that an audit of all practices should be made over a two-year period. This would mean that PCSA would be checking on average 5 practices per month. 2.5% of claims submitted by the practice will be verified. Checks actually commenced on 1 December 2004

Process

2.5% of GOS1 and GOS3 (sight tests and vouchers) claims submitted by the practice in the given month will be selected at random. The patient * will be sent a letter (letters with reference OPCHECK1 will be used) asking if the service was given. (Before any letters are sent, the Registration database will be checked to ensure the patients address has not changed or that the patient has not died). If no reply is received from the patient two subsequent reminders will be sent at two-week intervals. PCSA will record the number of claims paid in the given month, the number of claims extracted for verification and the results of the verification exercise. This will include the number of non-responders, if the service was received and the date on which the case was referred to LCFSU, if applicable.

*Patients aged over 65 will not be selected.

Role of the Local Counter Fraud Specialist Unit

Any responses that indicate the service was not delivered will be referred immediately to LCFSU.

Non-responders will be passed to LCFSU for further investigation if it is deemed necessary by them.

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3Patient 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 groups are:

  • Children under 16
  • Full time students under 19
  • Those aged over 60
  • Recipients of some tax credits
  • Recipients of some income based allowances (those patients will be in receipt of form HC2)
  • Those registered blind or partially sighted
  • Sufferers of diabetes
  • Those thought to be at risk of glaucoma, as defined by a ophthalmologist
  • Those over 40 and the parent/brother/sister/child of a person who has or had glaucoma
  • Those prescribed complex lenses

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.

The PCSA Board agreed on 24 March 2004 that 2.5% of those claims where evidence has not been seen should be audited. Patients should be asked to give evidence that they were entitled to the free or subsidised service or asked to pay the appropriate charge. Checks actually commenced on 1 December 2004.

Process

Each month 64 (an average 2.5 % of all claim types) claims where evidence was not seen will be selected at random using the audit facility within the ophthalmic payment system. An individual PCT will be selected each month on rotation. Depending on the type of claim and eligibility rules each claim should be verified. Where age is the criteria for eligibility claims will be checked against the Patient Registration system. Where eligibility is because of exemption on income grounds patients will be sent a letter (letters with reference OPCHECK2 will be used). Where eligibility is because the patient is registered blind or partially sighted PCSA will seek advice from the Communications Department on the best way to contact the patient. Before any letters are sent, the Registration database will be checked to ensure the patients address has not changed or that the patient has not died. If no reply is received from the patient two subsequent reminders will be sent at two-week intervals. PCSA will record the number of claims checked in the given month, the patients selected (so as not to duplicate in future audits) the results of the verification exercise (against each eligibility type) and costs recovered. The date on which referral to LCFSU will also be recorded if applicable. It should be noted that we are unable to verify if a patient is a relative of a glaucoma sufferer as this would involve a third party.

Recovery of NHS Costs

Any funds recovered will be credited to the non-discretionary General Ophthalmic Budget.

Role of Local Counter Fraud Specialist Unit

All non-responders will be referred to LCFSU as would patients who could not produce evidence of eligibility.

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The LCFSU will follow up non responders with a letter again (OPCHECK3) requesting the required confirmations and giving opportunity of personal contact either by phone or a visit as necessary. If there remains no response then confirmation of eligibility will be sought via Department of Works and Pensions and any cases where the patient is shown not to be eligible will be referred for consideration of further action.

4Comparison of Performance Indicators

The Ophthalmic Payments System contains a module that allows PCSA to produce Performance Indicators by PCT. These indicators can be used to highlight optometrists whose patterns of claiming fees are unusual and may require further negotiation. LCFSU and PCSA have met with the Local Ophthalmic Committee (LOC) to agree principles for investigation.

Currently LCFSU compare indicators by PCTs, on a quarterly basis. LCFSU calculate the PCT average, PCT standard deviation and the Avon average and Avon standard deviation. Any practices with more than 2 standard deviations from the mean on both comparisons are highlighted and the LOC are in agreement with this.

At present individual practices do not know how they ‘fair’ against other practices and it has been agreed that information will be issued to practices on a quarterly basis. Information will show all practices in the PCT area, however the information will be anonymised with the exception of the receiving practice. An example of the letter to be sent introducing the indicators (LCFSU1), examples of charts (LCFSU2 & 3), example of letter to accompany charts (LCFSU4) and an example of the report to be circulated to PCTs (LCFSU5) are attached. It should be noted that, on request, this information will also be sent to the LOC.

Process

PCSA will inform LCFSU when performance indicators are available each month. LCFSU will analyse the data and produce appropriate reports on a quarterly basis. These reports will be circulated to PCTs and local optical service providers. LCFS will ask recipients for comment.

5Comparison of individual claim types

Analysis of the ratios of cases in which glasses are prescribed against cases where none are prescribed, the incidence of claims for tints, prisms and small frame supplements should take place and the out-of-field cases should be investigated.

Process

PCSA will inform LCFSU when performance indicators are available each month. LCFSU will analyse the data and produce appropriate reports on a quarterly basis. These reports will be circulated to PCTs and local optical service providers. LCFS will ask recipients for comments. It should be noted that, on request, this information will also be sent to the LOC.

6The requirement for an Ophthalmic Advisor

Many investigations especially when assessing the outliers would benefit from the input of a clinician. The LOC, whilst finding the comparison data informative, feel that they

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are not in a position to review this information as their primary role is to support/advise optometrist colleagues. The LOC may on occasion be advising an optometrist regarding letters or information they have received on this subject from LCFSU. It is therefore strongly felt that PCTs should consider if an Ophthalmic Advisor should be employed on a sessional basis to carry out this role.

7LCFSU action to be taken with regard to Optometrists

LCFSU will investigate any cases that appear from the checks being undertaken by the PCSA with regard to alleged non-delivery of services.

The LCFSU will also investigate any anomalies arising from the outlier statistics and will inform the PCT’s and PCSA of the outcomes.

8Review of these procedures

The procedures outlined will be reviewed on an annual basis. This will be a responsibility of the Avon Primary Care Support Agency Management Board.

Julie CooperSue Edmonds

General ManagerManager

Avon Primary Care Support AgencyAvon Local Counter Fraud Specialist Unit

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Date:
Ref: / OPCHECK1 (a)
Audit of Services provided by an Optician

Patients name ………………….

Optician …………………………….

Date of glasses/lenses supplied ………………..

  1. What service did you receive? (Please put a ring around the correct answer)

1 pair of glasses/lensesYesNo

2 pairs of glasses/lensesYesNo

Bi-focalsYesNoDon’t know

TintYesNoDon’t know

PrismYesNoDon’t know

  1. If you had 2 pairs of glasses/lenses were the second pair supplied free under ‘a

offer' scheme run by the optician?YES/NO

3. Did you later need to have your glasses repaired or replaced? YES/NO

4. Please give any further comments on the service provided:

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

  1. Signed…………………………………. …….Date …………………………

Representative of patient………………………………………………………..

(if signing on behalf of the patient, please state relationship and also print your name)

Please return to: Mike Gardiner, Senior Payments Officer, Avon Primary Care Support Agency, King Square House, King Square, Bristol, BS2 8EE

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Date:
Ref: / OPCHECK1 (b)

Audit of Services provided by an Optician

Dear Patient

I am writing to ask for your help in an audit exercise we are currently undertaking.

When people have a sight test and are supplied with glasses, they may be entitled to treatment free of charge. When this happens, the optician submits a claim for payment of these charges to the Avon Primary Care Support Agency.

As a matter of routine the PCSA then carries out checks with a selected number of patients to confirm whether they have received the treatment, which is being claimed for by the optician.

I would therefore be grateful if you would complete the enclosed slip and return it to me by …………………….. in the reply paid envelope provided.

If you have any questions about this request, please do not hesitate to contact the Payments team on the number below.

Thank you for your help in this matter.

Yours sincerely

Mike Gardiner

Senior Payments Officer

Avon Primary Care Support Agency

Direct telephone: 0117 9002535

E-mail:

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Date:
Ref: / OPCHECK 1(c)

Audit of Services provided by an Optician

Dear ………………..

I am writing to ask you if you are in a position to reply to my letter dated …………….., a copy of which his attached.

A reply by …………….. would be very much appreciated. If you have any questions and would like to discuss the matter in person, then please contact the Payments section on the above number.

Thank you very much for your help in this matter.

Yours sincerely

Mike Gardiner

Senior Payments Officer

Avon Primary Care Support Agency

Direct telephone: 0117 9002535

E-mail:

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Date:
Ref: / OPCHECK1 (d)

Dear

We have written to you on two previous occasions, please see enclosed copies of letters.

The reason that audits such as these are carried out is to ensure the maintenance of high standards. We therefore need the input of information from people such as yourself to complete this work.

A reply to my letters by ______ would be very much appreciated. If you have a particular problem with the completion of the form as sent to you and/or would like to discuss the matter in person, please contact the Payments team on the above number.

Thank you for your help in this matter.

Yours sincerely

Mike Gardiner

Senior Payments Officer

Avon Primary Care Support Agency

Direct telephone: 0117 9002535

E-mail:

Enc

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Date:
Ref: / OPCHECK1 (e)

Dear

We have written to you on two previous occasions, see enclosed copies of letters.

The reason that audits such as these are carried out is to ensure the maintenance of high standards. We therefore need the input of information from people such as you to complete this work.

A reply to my letters by ……………………………………… would be very much appreciated. If you have a particular problem with the completion of the form as sent to you and/or would like to discuss the matter in person, please contact the Payments team on the above number.

Thank you very much for your help in this matter.

Yours sincerely

Mike Gardiner

Senior Payments Officer

Avon Primary Care Support Agency

Direct telephone: 0117 9002535

E-mail:

Enc

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Private & Confidential /
Date:
Ref: / OPCHECK2(a)

NHS Audit Exercise – Entitlement to claim exemption from paying Optical Charges

I am writing to you for your help in a NHS Audit Exercise we are currently undertaking.

We have received a claim for payment from ………….. in respect of a voucher towards the cost of your glasses which was supplied to you on …………..

The form which you completed at the opticians contains a declaration that was signed by you confirming exemption from payment of £…………….. by reason of …………………..

However the completed form submitted by the optician indicated that you did not provide any confirmation of this exemption at the time.

Therefore, as part of our audit exercise, I am asking if you would kindly provide us with confirmation of entitlement. A copy of a letter from the Department of Works & Pensions, a valid NHS Exemption Certificate, or a valid HC2 Certificate would be sufficient proof.

If you are a Full Time Student then we would require a letter from your School, College or University confirming this.

.

A reply to this letter should be sent using the pre-paid envelope enclosed by ……………………….., enclosing the relevant confirmation of your exemption from

paying the optical charges

Continued/………………..

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If you have any questions or are unsure on what to send us, then please contact the Payments team on the number below.

Thank you for your help.

Yours sincerely

Mike Gardiner

Senior Payments Officer

Avon Primary Care Support Agency

Direct telephone: 0117 9002535

E-mail:

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Private & Confidential /
Date:
Ref: / OPCHECK2(b)

Dear

NHS Audit Exercise – Entitlement to claim Exemption from paying Optical charges

You may recall that I wrote to you on …………… 2006 regarding the fact that you received optical services from …………………. on the ……….. Unfortunately I do not appear to have received a reply from you.

At the time of your visit you did not provide the Optician with evidence of your exemption from paying the charge of £……… I have enclosed a copy of the form that you signed confirming that you or your partner were exempt by reason of …………., and in the circumstance I would be grateful if you could forward evidence of your exemption for this reason, to me using the enclosed pre paid envelope.

If you now realise that you should have paid for the optical service then you should forward the relevant payment to this agency. Please make cheques payable to PCSA.

Please arrange for a reply to this letter by the ……………… either enclosing copies of the relevant documents or relevant payment.