Preventing Fraud In The NHS

Counter Fraud Services (CFS) was established within NHS National Services Scotland (NHS NSS) in June 2000 to combat fraud by Family Health Service contractors and patients against NHSScotland.

The investigative team was selected from a variety of backgrounds and with the expertise to pursue contractors who are suspected of claiming fees for treatment or services which may be fraudulent or in violation of the regulations.  The team is now fully operational with all investigators being accredited NHS counter fraud specialists. 

The patient team implemented new legislation on patient Penalty Charge Regulations and undertakes a national programme of patient checking to deter, detect and where appropriate recover charges from patients who have fraudulently or mistakenly claimed exemption from NHS charges.

Claims for help in meeting NHS Health costs and exemptions from payments total more than £370 Million a year.  But between 3-8% of all claims could be fraudulent or mistakenly claimed.  And every £10 Million that people who "can pay but won't pay" take out of the system, means the equivalent of:

• 20,000 FEWER Cataract operations, or
• 9,800 FEWER in-patients treated in hospital, or
• 3,800 FEWER hip operations, or
• 2,500 FEWER heart by-passes, or
• 400 FEWER nurses

Counter Fraud Services, part of the Practitioner Services Division of  NHS NSS, was formed in April 2000 to detect and deter patient and primary care contractor fraud.  CFS was sending out exemption verification letters to randomly selected patients who had claimed free prescriptions, dental or optical care asking them to prove that they were eligible.

To improve the efficiency and reach of this process CFS wished to implement an automated Patient Exemption Checking System (PECS).

Neil Billing, Head of Counter Fraud Services says, "We sent out one batch of letters at random and 5 out of every 100 patients simply sent back a cheque to pay for their prescription or treatment."

As an established partner with NHS NSS, we worked in close partnership with the CFS to define requirements and establish the scope of PECS.   In essence, PECS receives data from the Practitioner Services Divisions' Ophthalmic, Dental and Pharmacy payments systems.  Patients will be processed and, according to their exemption type, claims will be validated with the relevant agencies.  If the exemption is correct no further action is taken. 

If the exemption has been claimed fraudulently the system will trigger one of a number of standard letters to recover the debt.  We developed the Ophthalmic, Dental and Pharmacy payments systems using Oracle technology and it was decided to use this standard platform for PECS.  This allowed for reuse of common code, such as menus, and straightforward transfer of patient data from the payment systems.

Once the requirements were defined Sopra Group undertook the development on a fixed-price basis at their Queensway House premises.  To avoid delay and minimise disruption, User Acceptance Testing also took place at Sopra Group premises.

The timescale and budget for the project was very tight, however an intensive team approach to the analysis stage and careful Project Management by CFS and Sopra Group  ensured the solution was delivered to time and budget.

PECS is based on an Oracle database under Sun Solaris, with Oracle Forms and Reports on the Client side.  Oracle Discoverer is utilised as the ad-hoc reporting tool.

The PECS system replaced a manual system and has brought significant improvements in the exemption checking process.

Maggie Worsfold, Fraud Investigation Manager said "The new system has significantly improved the efficiency of our operations.  Preparing files for the checking agencies used to take us 3 days with the manual system, it now takes about 3 minutes.  The automated upload of data from the payment systems had considerably reduced our manual data capture and by the end of 2002 will allow us to increase the number of checks by almost 500% per month from the previous year."

Neil Billing acknowledges that the partnership between the two organisations was both close and extremely productive "The tight timescale meant that the analysis phase was crucial in fixing a scope that could be delivered to time and within budget, and since Sopra Group already had a working knowledge of the Payment Systems, they were able to grasp the concepts quickly and suggest the best way to extract information.  In the change from a manual system, Sopra Group's Analysts assisted us in realising what we actually needed to automate the processes."

By developing PECS using the same tools as the Dental, Ophthalmic and Pharmacy payments systems, software, hardware and support costs were minimised.  In addition, some of the functionality for these systems was reused reducing development costs and time.

PECS is now supported as part of the Sopra Group agreement for the Dental and Ophthalmic Payment Systems.  PECS resides on the same Sun Server and is proactively managed to ensure availability and security.

Now that PECS phase 1 is complete, CFS are already defining how this can be extended to serve the detection of patient fraud.