Annual QOF Review Process 200708 Random Counter Fraud Checks

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Annual QOF Review Process 2007/08 Random Counter
Fraud Checks

• For Thames Valley PCTs
• Provided by Thames Valley Primary Care Agency

2
National Guidance

• 5 of contractors subject to counter fraud check
  to ensure overall verification of claimed
  achievement
• Selection of contractors truly random
• Exclude contractors already subject to checks in
  both of previous two years
• Recommended annually, in May-July
• Separate from annual QOF review visit

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National Guidance (cont)

• More detailed version of pre-payment verification
  process, as a minimum covering
• Substantial discrepancies between annual review
  report and achievement claim submitted
• High/low prevalence not explained by practice
  demography
• High/low rates exception reporting
• Sudden large changes in figures month-month

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Reflections on 2006/07 Process

• Inconsistencies in interpretation of indicators
• Between PCTs
• Between visiting assessors
• Between 5 verification and PCT pre-payment
  verification processes
• Selection of patient records inconsistent
• Number, randomness
• Variable ease of assessors access to records in
  different practices

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Reflections on 2006/07 Process (cont)

• Integration of PCT pre-payment verification
  processes and 5 check process not good
• Selection and training of assessors did not
  enhance consistency
• Contractor practices not well prepared for visits
• Communication about purpose and process needs
  improving

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Selection of Contractors

• Chosen randomly by Thames Valley LMCs executive
  from list of contractors provided by TVPCA
• 5 of contractors in each PCT, rounded up
• Contractors visited in either of last 2 years are
  excluded
• BE 3, BW 3, Bucks 3, MK 2, Oxon 4 (n 15)

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Plans for 2007-08 Process

• Aim to carry out visits in May July
• Initial letter to contractors explains
• Expected duration of visit
• People and facilities needing to be made
  available
• Reporting process

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Preparation for Visits

• Discuss with each PCT QOF lead, for each practice
• Results of QOF review visit, if any
• Findings of pre-payment verification process
• Any concerns about claimed achievement of
  specific indicators
• Any concerns about prevalence or exception
  reporting rates

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Preparation for Visits (cont)

• PCT to provide 5 assessor team, for each
  contractor
• Copy of QMAS final achievement report
• Copy of any QOF review visit report
• Copy of any evidence submitted to PCT, with PCTs
  comments on this
• Analysis/commentary on relative prevalence and
  rates of exception reporting
• Copies of local guidance issued re QOF
  indicators, including ante-natal and child health
  surveillance

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Content Focus of Visit

• Agreed in advance with PCT for each contractor
• Mix of standard and practice-specific checks
• Clinical domain indicators
• Register accuracy, use of exception reporting,
  has necessary work been done? (e.g. patient
  reviews)
• Other domain indicators
• Contractor policies and protocols, audit results,
  medication reviews, notes summarisation
• Patient experience domain indicators

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Visit Requirements

• Full set of Grade A and B evidence
• Access to clinical computer system throughout
  visit (expect 1030 1530 minimum)
• With informed user to support (e.g. computer
  administrator)
• Available for discussion with assessors
• Clinical QOF lead
• Managerial QOF lead
• Other practice staff as needed

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Review of Clinical Records

• Where possible, TVPCA will provide lists of
  patients for random selection by assessors
• Contractor to make available lists of patients on
  individual QOF disease registers
• Assessors will select initial 10 records at
  random, supplementing these to allow for excepted
  patients
• More randomly selected records if achievement in
  doubt

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Visiting Assessors

• Two Probity Performance Officers from TVPCA
• One clinical assessor from team of 4
• Experienced GP
• Not current contractor
• May be recently retired from practice
• Do they need to be clinically up-to-date?

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Reporting Findings

• Basis is objective assessment of compliance with
  SFE guidance
• Is the contractor able to demonstrate that it has
  met the SFE requirements for those indicators it
  has claimed achievement?
• Draft report to PCT within one week of visit
• Draft report to contractor within 3 weeks
• All comments to be made within 3 weeks of receipt
• Final report within one week of receipt of
  comments or 4 weeks of draft report sent

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Reporting Findings (cont)

• TVPCA team submits final report to PCT
• Copied to contractor
• PCT makes decision about any action needed, for
  example
• Further visit(s) to contractor to investigate
  claimed achievement
• Training and support for contractor
• Recovery of incorrectly paid monies

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QOF Indicators Needing Clarification of
Interpretation

• What is sufficient to demonstrate achievement?

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Clinical Indicators

• Clinical review carried out
• Asthma 6
• Dementia 2
• Mental Health 9
• What counts as sufficient for the relevant
  review?
• Every point in SFE checked, or only some/one?
• How much clinical discretion is allowable?

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Organisational Indicators

• Records 15, 18 20
• What is meant by an up-to-date clinical
  summary?
• Records 19
• What is acceptable for notes summarisation
• Medicines Management 11 12
• What is sufficient for a medication review
• Education 10
• How closely must practices comply with SFE
  detail?

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Additional Services Indicators

• Cervical Screening 7
• What should an acceptable practice protocol
  include?
• Every item specified in SFE?
• Only one or some?
• Practice/contractor specificity and ownership
• SFE says this protocol may have been drawn up
  outwith the practice

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Practice Policies and Protocols

• General questions
• How much do these need to be practice-specific?
• Should they be owned by the contractor and
  practice team?
• Do they need to be live, working documents?
• What about clinical content where relevant?
• Note instances where practice managers
  (non-clinicians) appear to deal with all
  organisational domain indicators
• For example, antenatal care, significant event
  reviews

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Patient Experience Indicators 5 6

• How closely must practices comply with the detail
  provided in the SFE?
• What is sufficient for an action plan?
• Must practices demonstrate in their action plans
  that
• each of the 3 criteria are met for PE5, and
• each of the 4 criteria are met for PE6?
• (note these worth 50 points in total, c. 6,000)

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Further Comments Questions?