Risky business

An investigator from NHS Scotland Counter Fraud Services discusses the work he does in the dental sector.

NEWSPAPER and online news headlines often paint a stark picture of the more extreme side of dental fraud. ‘Dentist jailed for £300,000 NHS fraud’ read one BBC article in November 2010 while another in October was headlined ‘Dodgy dentist’s unknown fraud haul’.

While dental fraud can make dramatic news, it is not the exclusive preserve of the determined cheat. Unintentional errors can be made due to lack of awareness, or a misunderstanding of the regulations. A dentist might, for example, claim 100 per cent of an NHS allowance, without realising that the proportion of private income they have earned has risen above the 10 per cent threshold specified in the regulations. By not keeping on top of their accounts, that dentist will have unwittingly made a false claim – which is technically fraud.

As dentists starting out in the profession, having an understanding of the role of the Counter Fraud Services (CFS) team will help ensure that you can play your part in protecting the resources of the NHS.

Who are we?

CFS is a division of NHS National Services Scotland (NHS NSS) and works with all of Scotland’s health boards. All CFS investigators are professionally trained and accredited and we are dedicated to deterring, detecting and investigating fraud. The CFS code of practice ensures we are objective and fair.

My colleagues have experience of investigating fraud in other public sector law enforcement organisations, some have private sector experience, whilst others have an NHS background. Some have studied fraud, criminal justice and law, giving the organisation a broad range of knowledge and skills.

As you start your career in dentistry you will likely hope to never have to engage with CFS in any capacity, let alone find yourself as a suspect in a fraud investigation that could lead to criminal court proceedings.

But it’s important to understand what we do and the types of fraud we investigate. One common example is if a dentist claims NHS payments for treatment and/or services that have not been provided, such as replacing a set of dentures when the dentures have in fact been repaired. Another is double charging, which can occur when dentists charge non-exempt patients and then falsely claim exemption from the NHS, or when they charge patients privately and then claim for the same treatment from the NHS. Other types of fraud include claiming payment for precious metal dental restorations that contain no gold or precious metal and claiming for domiciliary visits which were not undertaken.

Investigative process

The investigative work that CFS does is divided into two streams. The first involves the proactive team which works with our statistician to analyse claim data and look for potentially suspicious patterns. Proactive investigation into these patterns may not uncover any fraud or it could result in an investigation being launched into one or more dentists.

The second stream involves the Payment Verification (PV) team at Practitioner Services (PSD) (a division of NHS NSS), who ensure payments made to practices are valid. Here is where many dental fraud allegations emerge. I rely upon my PV colleagues to answer technical queries so that we can present the evidence in a way that is easily understood by legal professionals and jurors (should the case go to court).

The status of CFS also allows me to report offences direct to the Procurator Fiscal Service, without involving the police.

Objective

When allocated a case, I have to objectively assess the alleged fraud. Typically, at a meeting between PSD, CFS and the dentist’s health board, we discuss the allegation and decide upon the initial parameters of the investigation. My goal at this stage is to identify key witnesses, where to find the evidence, and to determine whether a prosecution is feasible and what defence may be offered by the dentist.

In most circumstances the dentist is made aware of CFS enquiries when they receive a letter asking them to voluntarily supply patient records. This would not be the case if records were obtained by other means, or if the dentist were to find out informally, for example through patient enquiries. Many dentists seek legal advice before responding to our request. But if they don’t comply, I would consider asking the Procurator Fiscal Service to obtain a search warrant in order to retrieve evidence from the dental practice or elsewhere.

When evidence has been gathered and witnesses interviewed, CFS invites the dentist to attend an interview, usually accompanied by their solicitor, and as an investigator I go in with an open mind. Generally it takes place in NHS accommodation and is tape-recorded. If I have reasonable grounds to suspect the dentist has committed the offence, then I would caution them that their statement may be used in evidence in criminal proceedings. At this interview the dentist has an opportunity to explain the apparently incriminating evidence.

After the interview and any necessary follow-up enquiries, I would review the case with my manager and decide whether a report to the Procurator Fiscal is appropriate. It is a decision that requires some consideration, as the consequences for a dentist convicted of fraud against the NHS are many – a prison sentence, fine, suspension or they may be struck off the GDC register.

If the decision is not to refer, or if the Fiscal decides not to take criminal proceedings, a report is sent to the relevant health board recommending further action. This may include reporting the matter to their Reference Committee to decide whether the matter should be referred to the GDC. CFS may also recommend that the health board recovers any overpaid claims from the suspect.

Advice points

Good record keeping is extremely important in avoiding allegations of dental fraud. Comprehensive notes will help avoid mistakes when claiming for dental treatments or services and provide evidence to support your claims.

I would also suggest that you become familiar with the NHS claiming process in your practice to make sure that the treatment you prescribe is the treatment being claimed in your name. Fee scales can be complex so always check the number of items and allowances and the conditions that apply to them. Don’t rely on the advice of a colleague. If in doubt, contact the appropriate paying authority.

You should never claim more than your entitlement because you think the system is unfair or doesn’t offer sufficient remuneration for the amount of work you have put in. Some procedures may not yield large rewards for the complex work involved, but these small deceptions are not worth the risk of a fraud investigation and potential professional trouble with the GDC.

Never make false claims or invent patients in a bid to relieve short-term financial troubles. You may think the deception has gone unnoticed but the system will most likely catch up with you further down the line. Contact your professional association for advice if you find yourself in difficulty.

If you provide a service to NHS Scotland, you have a moral obligation to help prevent fraud. Only a very small number of healthcare professionals seek to defraud the NHS, but our aim is to identify those areas of misuse of resources, ensuring that money intended for the provision of frontline healthcare is spent where it is intended. For further information go to www.cfs.scot.nhs.uk

The author works as an investigator for NHS Scotland Counter Fraud Services

 

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