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Plain To See

3 May 2013

How can optical practices focus on reducing the scope they offer for fraud?

The National Health Service is seen by many as a huge, impersonal organisation with a huge budget and some flaws in its structure. Which, in the eyes of some unprincipled people, make it an ideal target for fraud.

Any company or public body with an annual budget as large as the NHS’s £110 billion cannot help but attract the odd person looking to make an illegal gain. To its credit, the NHS is now more acutely aware that it is a target for systematic fraud; usually involving high-volume, low-value activities that are carried out regularly. Considered estimates would have us believe that fraud now eats away around 3% of the NHS budget. That belief has seen a growing anti-fraud culture in the NHS, which was perhaps inevitable.

This anti-fraud culture should be welcomed. In fact, many of us will wonder why it wasn’t in place many years ago. But while it can only be seen as a good thing, it also has to be considered a warning to many professionals working in the NHS; namely doctors, dentists and opticians. Rahman Ravelli has successfully represented clients who are health professionals that have been wrongly accused of fraudulent activity within the NHS.

We were recently involved in a case involving allegations of a complex conspiracy by a dental practice to defraud an NHS trust. It was based on the way the practice was run under the dental contract. We argued that that from day one the prosecution showed a lack of judgement and an inability to understand the nature of the 2006 dental contract. More than two years later, when it came to trial, the judge said the prosecution case was ill conceived and stayed the charge of conspiracy to defraud the primary care trust. Similarly, we have represented GP’s who have faced accusations of wrongdoing when carrying out their duties.

Our success in such cases has been achieved because we were able to back up our arguments with solid, documentary evidence and testimony. With this in mind, it is important that optical practices remember a few essential points when carrying out their day-to-day duties. There can be no doubt that even the most honest opticians now have to be careful about how they run their practices if they are to avoid investigation.

The optical profession has certainly done much to promote integrity in its ranks. The General Optical Council, as the regulator of the industry, takes great efforts to ensure the highest standards in conduct, qualifications and professionalism among its 26,000 members so that the general public can benefit from top-quality eye care. Similarly, the Association of Optometrists (AOP) makes it its mission to represent its members and sustain the highest standards of practice among them. Yet in 1997, the Healthcare Financial Management Association pinpointed the scope for fraud within optical practices. The GOC and AOP can point to the strong culture of sound professionalism they encourage. But the media has reported on opticians claiming for work that was not carried out, stating patients were exempt from payment so payment could be claimed from the NHS even though the patient had paid, inventing non-existent patients or claiming for work on patients who had actually died. Some cases have come to light after concerns about opticians were voiced by patients or colleagues while others were detected by the NHS Counter Fraud Service.

If allegations are made against an optician it can mean their practice and other related properties being raided. This can make it extremely difficult to keep the practice open, running and managed effectively, not to mention the damage it can do to an optician’s reputation. When such potential problems are considered, the need to be able to challenge the allegations as effectively and quickly as possible becomes even more important. But this can only really be done if an anti-fraud culture already exists in the practice. Backing up claims of innocence can only be done effectively with solid, documentary evidence and testimony. With this in mind, it is important that optical practices remember a few essential points when carrying out their day-to-day duties. These points will not only make it easier to rebut any allegations that may be made – they will also reduce the scope for any fraud to be carried out in the first place.

Firstly, comprehensive records of work booked in, performed and billed for must be kept contemporaneously. There can be no lag in completing the paperwork – and all such records must be kept in duplicate and filed away. Pre-empting any investigation and the questions that are likely to follow will be far easier if the practice has easy access to an up-to-date, accurate and contemporaneous record-keeping system.

Secondly, the practice needs to look at the potential for fraud in the way it operates. This is important whether or not the people running the practice believe or suspect that fraud is being carried out. All aspects of the way the practice operates should be examined closely. It may be worth bringing in legal experts in the field of compliance. They can help the practice ensure it is run in a way that shows clearly to anyone that it offers absolutely no potential for fraud. Such legal expertise could advise a practice on how it should react if it should come under investigation for fraud. But first and foremost a practice has to make sure it is operating in a manner that allows little or no scope for fraud, so that if it did ever occur, it could be flagged up and acted upon immediately.

Fraud in the optical world may never be totally eradicated. The potential will always exist due to the triangular patient – optician – NHS arrangement that exists. In some cases, it may even be carried out by an optician unknowingly if records and payments are not organised as meticulously as they should be. But practices can - with a little forethought and the right legal help - ensure that both the potential for fraud and their liability for it are minimised.


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