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Practices with outlying exception reporting rates face fraud investigations

By Lilian Anekwe

GPs across the country are being investigated for fraud by PCTs determined to root out inappropriate levels of exception reporting, Pulse can reveal.

At least nine trusts have instigated proceedings against practices suspected of fraudulently excluding patients, as part of a tough new stance against gaming in the QOF.

PCTs have commissioned specialist counter-fraud teams to scrutinise exception reporting rates in practices that can't satisfactorily justify their figures – with formal fraud investigations launched if practices are deemed to be acting outside of the law.

Our investigation into PCTs' crackdown on QOF gaming revealed last month that one in six trusts had docked QOF points from GP practices whose exception reporting rates were deemed unacceptable.

The latest revelations underline the lengths managers intend to go to reduce their bill from exception reporting bill – which a study last week estimated cost the NHS £17 million.

Central Lancashire PCT said it would instigate proceedings against practices ‘where significant areas of concern remain for which no reasonable explanation can be given.'

And a spokesperson for South West Essex PCT told Pulse. ‘If a practice continued to exception report inappropriately, despite PCT advice and recommendation, and the PCT believed it to be fraudulent, it would be referred to the counter-fraud specialist.'

In Peterborough PCT, practices are being investigated for potential fraud ‘where a practice has patients on the system which have left the practice, where clinical comments do not substantiate the need for exception reporting and where IT system data does not correspond with manual records'.

Dr Simon Poole, chair of Cambridge LMC and a GP in Histon, Cambridgeshire, said: ‘It's justified if practices are found to be demonstrably defrauding the system. But I'm not sure how useful it is. It's not my experience of day to day practice.

Dr Poole insisted he would expect the PCT to consult the LMC first, to avoid practices being placed under unacceptable pressure. ‘The LMC would have to agree that the practice was acting outside of the law.'

Common grounds for fraud investigation

- A practice is unable to give a valid explanation of exception reporting
- Exception reporting has been used to increase payments in QOF
- There are multiple examples of inappropriate exception reporting in a single practice
- If information has been changed after the initial entry
- The practice is uncooperative or unwilling to provide information

Source: Document from Dudley PCT

Practice high rates of exception reporting could be investigated for fraud Practice high rates of exception reporting could be investigated for fraud

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