FRAUD

1
FRAUD CORRUPTIONIN THE NHS
Bournemouth and Poole PCT / Dorset PCT LPC
Presentation

• Steve Plant / Patrick Kelly
• Local Counter Fraud Specialists
• Dorset Somerset Counter Fraud Service

2
Introduction

• Ms lost to fraud, corruption and error
• Majority of staff, contractors and patients are
  honest small minority are not
• Deprived of valuable resources which should be
  spent on patient care
• Examples of fraud range from false travel claims
  by staff to complex and high value fraud

3
WHAT IS FRAUD?

• 3 elements to committing fraud
• A dishonest act (or failure to act)
• With intent
• To make a gain or causing a loss
• Does not have to be successful
• Does not have to be personal gain

4
WHAT IS FRAUD

• According to the law (Fraud Act 2006)
• s.2 By false representation
• s.3 By failing to disclose
• s.4 by abuse of position of trust (corruption)

5
Who commits fraud?

• Four main groups of people
• Staff
• Patients
• Contractors (GPs, pharmacists etc)
• Suppliers of goods

6
Main types of fraud

• Timesheet fraud
• bank, overtime, enhancements
• Working elsewhere whilst sick
• Obtaining drugs by deception
• Procurement fraud (corruption)
• Invoicing for goods not provided
• Claiming for services not provided

7
Patient Fraud

• False Registration
• Temporary or permanent
• Fraudulently obtaining duplicate scripts
• Original lost or stolen
• Theft of blank prescriptions
• Altering prescriptions
• Adding items or changing quantity
• Claiming false exemption from charges

8
False Identity Fraud

• A Gosport woman made over 200 false temporary
  registrations over 4 years.
• Using different identities, obtained Co-Drydamol
  to feed her addiction.
• Convicted in 2004 and again in 2005 for obtaining
  drugs by deception from Hampshire GPs,
• Moved area of operation to Dorset and then Isle
  of Wight.
• Convicted again in May 2008 and received an 18
  months supervised community sentence.

9
Theft and forgery of prescriptions

• Patient arrested and admitted stealing
  prescriptions
• Scanned stolen blank prescriptions to set up a
  template on his PC at home
• Generated prescriptions for Dihydrocodeine and
  Lorazepam
• Charged with theft and two charges of obtaining
  property by deception
• Given an 18 month Community Rehabilitation order

10
GP obtained drugs by fraud

• A GP forged prescriptions to obtain drugs
• He presented a prescription to pharmacy in his
  sons name
• Issued 22 prescriptions for codeine phosphate and
  dihydrocodeine in names of various patients
• All the drugs collected by the GP but patients
  never received medication
• 18 other offences taken into consideration
• Suspended by the PCT
• Pleaded guilty, fined 3,000 and ordered to pay
  250 in compensation

11
Pharmacy Reward Scheme

• Details of stolen prescriptions are circulated by
  the PCT
• Potentially altered or forged prescriptions
  should be checked with the prescriber
• Pharmacists are advised to phone the police if a
  patient presents a stolen, altered or forged
  prescription
• May be eligible for a 70 reward

12
Pharmacy Reward Scheme

• Part XIV of the Drugs Tariff
• Pharmacists are eligible for a 70 reward if
• The fraudulent prescription is withheld the
  drugs are not dispensed,
• OR The fraudulent prescription is dispensed but
  the Pharmacist had a genuine reason for
  dispensing the medication,
• AND The PCT is advised as soon as possible,
• AND NHS CFSMS are advised within 7 days and a
  claim is made within 28 days

13
Patient Verification Service

• Patients required to show proof of exemption from
  payment of prescription charge e.g.
• Award letter from DWP for a relevant benefit
• Income Support, or
• Income based Job Seekers Allowance, or
• Income based Employment and Support Allowance
• NHS tax credit exemption certificate
• Valid HC2 certificate
• FP96 pre-payment Card

14
Patient Verification Service

• Only certain benefits give exemption
• The following DO NOT exempt patients from
  charges
• Incapacity Benefit
• Disability Living Allowance
• Contribution based Job Seekers Allowance
• Contribution based Employment and Support
  Allowance

15
Patient Verification Service

• Pharmacy should request evidence of exemption
• If not provided, the back of the prescription
  should be marked with an X
• These may be checked at a later date by the
  Patient Verification Officer at Counter Fraud
  Service
• If patient found to have falsely claimed
  exemption a penalty charge will be issued

16
Patient Verification Service

• Civil Fine
• 5 times the amount owed up to a maximum of 100
• In addition to the original charge
• 50 surcharge (Penalty only)
• Repeat offenders may be prosecuted

17
Pharmacy Fraud

• A Leeds Pharmacist received payment for
  prescriptions from patients, but then claimed
  that the patients were exempt from charges so he
  could recoup the money from the NHS
• An investigation by NHS Counter Fraud Specialists
  found that since the pharmacy was purchased in
  May 2003, there had been a 50 decrease in the
  number of prescriptions paid for by patients
• He was arrested at his pharmacy and later charged
  with 13 counts of obtaining a money transfer by
  deception and False Accounting
• He pleaded not guilty at Court but was convicted
  by jury after a two week trial and was jailed for
  9 months

18
Pharmacy Fraud

• Pharmacist applied to PCT to take part in their
  stop-smoking programme
• Entitled to claim payment for each consultation
  and nicotine replacement therapy service he
  provided, with a bonus if a set quota of
  participants successfully completed the scheme
• An investigation revealed that he had claimed
  payment for more treatments than he provided, and
  claimed that some participants had completed the
  scheme when they had not
• One man who he claimed had been provided with NRT
  and successfully completed the scheme, had never
  attended his pharmacy
• He pleaded not guilty to four counts of false
  accounting but was found guilty on three counts
  by the jury, fined 3,000 and ordered to pay
  1,500 prosecution costs

19
Other areas of concern

• Medicine Use Reviews
• Repeat Ordering Service
• Ordering all items on repeat but only dispensing
  some
• Fees for special preparations
• Suppliers offering discounts (or kickbacks?)
• 7 day prescribing
• 28 day calendar packs

20
Contact Details

• Steve Plant, Local Counter Fraud Specialist
• Work Telephone [phone]
• Mobile [phone]
• E-mail _at_steve.plant_at_dorset-pct.nhs.uk
• DSCFS website http//nww.dascfs.nhs.uk
• Fraud Hotline [phone]
• Public Concern at Work 0207 404 6609