Ouch!! Dentists under examination as dental fraud becomes a painful truth

Here, Rahman Ravelli examines the true situation regarding dentists and fraud and suggests ways practices can give themselves a check up.

AN ESTIMATED £70M-plus is being lost each year to dental fraud. It is thought that an even larger amount than that will fall victim to fraud in dentistry before the problem is put right.

The figures come from watchdog NHS Protect, which says it uncovered appalling levels of fraud. In the year it reviewed (2009-10), it discovered that £73.1M was paid out for fraudulent claims by dentists for work that was never carried out. NHS Protect warns that with new dental contracts not expected to be in place until 2014, there is scope for almost two years’ further fraud on a similar scale. The Office of Fair Trading (OFT) wants new NHS dental contracts introduced as soon as possible to ensure more patient choice, greater ease of entry into the market by new dental practices and the chance for better performing practices to expand. Now, it seems, the dentists are coming under as close a scrutiny as their patients.

Much of the blame for the alleged fraud is placed on changes made to the NHS dentistry contract system in 2006. The changes were intended to improve patient access to dental services, following concerns that millions of people were unable to register with NHS dentists.  These changes meant that payment for NHS dentistry was not tied to one particular course of treatment, such as a filling or crown. Under the changes, treatment was categorised into three groups. The problem that this caused, according to NHS Protect, was that it gave dentists scope for fraudulent claims. Instead of claiming for a specific filling or crown, dentists simply had to state which group of treatment they were claiming payment for. And NHS Protect’s review of a random 5,000 bills submitted by dentists showed that many were claiming for having done more expensive work than they had actually carried out.  NHS Protect believes 3% of the annual 37.5 million claims made each year could be fraudulent – more than a million a year.
Last year, the Office of Fair Trading (OFT) called for changes to the £5.73 billion-a-year UK dentistry market after its study found that patients have insufficient information to make informed decisions about their choice of dentist and the dental treatment they receive.

In its report, the OFT says: “We are particularly concerned to find that around 500,000 patients each year may be provided with inaccurate information by their dentist regarding their entitlement to receive particular dental treatments on the NHS and, as a result, be required to pay more to receive private dental treatment unnecessarily.
’’ Evidence gathered by the OFT suggests that NHS commissioning bodies and the General Dental Council (GDC) need to be far more proactive in identifying and pursuing formal, robust and timely enforcement action against such instances of misconduct where appropriate.’’
The OFT wants the GDC to take “more robust and timely disciplinary action’’ against instances of misconduct by dentists and calls on the British Dental Association (BDA) to develop an effective code of practice to ensure dentists’ selling of dental payment plans does not breach consumer protection law. According to the OFT, there needs to be a simpler, quicker complaints process that can be used by dental patients.

In response to fears of fraud, the UK government has said it will introduce a new contract system that will not only improve people’s access to good dental treatment – it is also aimed at reducing the risk of dental fraud. Under the new proposals, there will be more scope for analysing dental contracts to detect irregular, suspect or otherwise unaccounted-for activity much earlier. According to the government, it plans to alter the way dental treatment is recorded in a way that will remove the potential for fraudulent claims while promoting awareness of the risks of such fraud. It intends to promote a more uniform way of working for all NHS dentistry services.
NHS Protect has said it will continue to monitor the risks of fraud within the NHS’ dentistry sector. The upshot of all this is that dentists, their staff and practice managers are all now likely to be scrutinised in a much closer way than they ever have been before. Whether the government is following the old argument that “one bad apple spoils the whole barrel’’ or simply believes that a few rogue dentists are tarnishing the reputation of thousands of honest ones has not been made expressly clear. But what we do now know is that there is fraud in dental circles and the authorities are out to eradicate it.

It is because of this new awareness that even the most honest dentists now have to be especially careful about how they do business. At Rahman Ravelli, we have been involved in cases where dentists have acted in good faith in carrying out first-class treatment and have billed for the work accordingly – and yet they have still found themselves under investigation.

We were recently involved in a case where a complex conspiracy by a dental practice to defraud an NHS trust was alleged. These allegations centred on how the practice was run under the dental contract and the way it treated patients. The practice and other related properties were raided, our client’s ability to continue managing the practice was hampered and patient treatment was disrupted. 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. This case was the one that was named Operation Groat by police.

We believe that from day one the prosecution showed a lack of judgement and an inability to understand the nature of the 2006 dental contract.  As a result, a contractual dispute over payments to the practice under the national dental contract was allowed to mutate into a criminal prosecution. In our arguments, we pointed to the proceedings being an abuse of the court’s process. We highlighted the fact that not only had no fraud been perpetrated but that the PCT had raised no concerns about the operation of the dental practice. The practice was saving the PCT money and by offering what it called “private options’’ it was giving the maximum possible amount of patients the best treatment given the limits on what it could provide under its NHS dental contract. Most NHS dental fraud involves a practice charging for patients that were never treated or, if they were, sees the practice inflating the amount of treatment supplied to gain extra money from the PCT. The practice we represented was actually being prosecuted for devising a way of costing the PCT less money.

Our arguments and those of our fellow defence team solicitors were accepted by the court, leading to the prosecution coming to an end. But it could only be stayed because we were able to back up our arguments with solid, documentary evidence and testimony. With this in mind, it is important that dental practices remember a few essential points when carrying out their day-to-day duties.

Firstly, comprehensive records of work booked, carried out and billed for must be kept contemporaneously. There can be no lag in completing the paperwork – and all records must be kept in duplicate and filed away. If practices are worried about what they should be doing to pre-empt any investigation, then having an up-to-date, accurate and contemporaneous record-keeping system is the essential activity they should be carrying out.

Secondly, they need to look at the potential for fraud in the operation of the practice, regardless of whether they believe or suspect that it is happening. All aspects of the way the practice operates should be examined closely. In some cases, it will be advisable for them to enlist the help of legal experts in the field of compliance. Such experts can help the practice ensure it is run in a way that means it could show 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 and, if fraud did ever occur, it could be flagged up and acted upon immediately.

Fraud in dentistry may not ever be totally eradicated. It may not even, in many cases, be being carried out intentionally. But practices can - with a little forethought and the right legal help - ensure that both the potential for fraud and their liability for it is minimised.