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GPs face exception reporting fraud spotchecks

Exception reporting under the quality framework has been identified by primary care organisations as the highest risk area for fraud under the new contract, writes Rob Gough.

As the Read codes for exception reporting were released by the NHS Information Authority, GPs were warned that any practice with higher-than-average rates of reporting could face a fraud investigation.

The warnings cast doubt on the high-trust principle that underpins monitoring of GP claims for payment under the new contract. The exception reporting codes allow GPs to exclude patients from quality pay calculations on the basis they are 'unsuitable' or have given informed dissent.

Dr Tony Snell, who was the NHS Confederation's lead negotiator on the quality framework, said exception reporting would not be covered by the 'high-trust' principle: 'That's where there is the biggest risk of problems.' He warned GPs to keep full documentation of every exception report. 'If an audit trail is not visible there would be a problem.'

NHS Alliance contract lead Dr David Jenner predicted PCTs would set local benchmarks and investigate practices reporting 'significantly more exceptions than average'.

Other factors may also prompt a spotcheck. 'If data was presented late, was shabbily presented or was altered ­ all these things would come into that sort of a decision.'

Dr Jenner, a GP in Collom-pton, Devon, added: 'There may need to be some random spot audit on every practice to check exception codes are being used with probity.'

­ somewhat like the Inland Revenue.'

­ at the worst level it would be fraud.'

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