Operations Directorate Counter Fraud and Probity Services

2010/11

Annual Report

Operations Directorate

Counter Fraud and Probity Services

Organisation Business Services

COUNTER FRAUD AND PROBITY SERVICES | 2010/11 ANNUAL REPORT Page | 0

Contents

Message from the Chief Executive................................ 01

Foreword................................................................................. 02

Widening the Scope............................................................ 03 Counter Fraud Services..................................................... 04

Investigation Outcomes.......................................... 05

Probity Services.................................................................... 06

Probity Outcomes..................................................... 07 Patient Exemption Verification............................. 08

Healthy Start/Day Care Foods.............................. 09

Policy and Fraud Awareness........................................... 10

Working together. Achieving more.............................. 12 Going Forward....................................................................... 13 Annexes

Annex 1: CFPS Structure............................................. 14

†

While the true extent of healthcare fraud in Northern Ireland is not currently known recent studies indicate that between 3 – 6% of global healthcare budgets are at risk to fraudulent and corrupt practices.

The Financial Cost of Healthcare Fraud Report was published jointly in 2009 by MacIntyre Hudson LLP, the Centre for Counter Fraud Services at University of Portsmouth, and the European Healthcare Fraud and Corruption Network.

Even a 1% loss could put £40 million of our healthcare budget at risk.

†

†

In 2010/11 patient fraud and error cost £2.2 million.

COUNTER FRAUD AND PROBITY SERVICES | 2010/11 ANNUAL REPORT


Message from the Chief Executive I am pleased to endorse the 2010/11 Annual Report for the BSO‟s Counter Fraud and Probity Services (CFPS). This has been a year of significant progress for CFPS, with the establishment of an expanded HSC-wide fraud investigation service, the

setting up of two new operational hubs for primary care probity activity in Armagh and Londonderry, the relocation of the Day Care Foods Service and the Patient Charges Verification work from Franklin Street, and the provision of fraud awareness tools to HSC client organisations. In an operating environment, where financial constraints and service demands continue to increase year on year, it is crucially important that the BSO meets the requirements and needs of its customers in the most effective manner possible. In seeking to mould and deliver these services, I recognise the ongoing support and co-operation of colleagues across the HSC. I look forward to further development and enhancement of the range of specialist services provided by CFPS in the years to come. David Bingham Chief Executive Business Services Organisation August 2011

The HSC has a zero tolerance policy on fraud and requires all staff at all times to act honestly and with integrity, and to safeguard the public resources for which they are responsible.

COUNTER FRAUD AND PROBITY SERVICES | 2010/11 ANNUAL REPORT | PAGE 1


Foreword

In my role as Director of Operations, I see at first hand the range of services provided to HSC client organisations by Counter Fraud and Probity Services – formal fraud investigations, fraud awareness and fraud policy development,

primary care probity verification services, verification of patient exemption from charges and the administration of the Day Care Foods component of the UK-wide Healthy Start Scheme. CFPS staff in conjunction with their clients have made strenuous efforts throughout the last 12 months to hone and fine-tune service provision to ensure it meets requirements and is fit for purpose. The last 12 months have seen substantial change and progress with the establishment of the expanded fraud investigation service and the consolidation of a regional primary care probity service in two operational hubs in Armagh and Londonderry. I commend the CFPS team for their hard work and dedication in what has been a challenging year of both transformation and further consolidation. Progress is not made by “standing still” and I look forward to working with my team in CFPS as we move into still more challenging times.

Teresa Molloy Director of Operations Business Services Organisation

Avoiding payment of statutory dental or ophthalmic charges Theft of cash and equipment False accounting Falsely obtaining access to non emergency treatment

Flexi/sick leave abuse False claims for travel, overtime or subsistence

Examples of fraud



Widening the Scope Counter Fraud and Probity Services (CFPS) was established in April 2009, bringing together probity services, previously delivered by the 4 legacy Health Boards, the counter fraud and probity policy remit, previously discharged by DHSSPS, and the

Counter Fraud Unit of the former Central Services Agency. The remit of CFPS includes:

tackling fraudulent claims by patients to exemption from statutory dental and ophthalmic charges;

formal investigation of cases of potential or suspected fraud across all Health and Social Care organisations;

delivery of a range of probity verification and assurance work in relation to Primary Care contractors;

counter fraud and probity policy issues;

the administration of the Healthy Start Scheme in Northern Ireland.

Making a Difference

CFPS, working with DHSSPS and Health and Social Care organisations, is committed to:

the delivery of high quality, cost effective and efficient services to our clients;

the provision of a range of assurances to HSCB in relation to payment claims submitted by Primary Care contractors;

the reduction of fraud and corruption across the HSC to an absolute minimum;

the building and promotion of a culture in which staff, patients, contractors and the wider public regard fraud against the Health Service as totally unacceptable; and

the safeguarding and, where appropriate, recovery of misappropriated funds for reinvestment in front line services.

£5 million could pay for 500 coronary artery bypass procedures.


A GP was investigated for manipulating patient records in order to claim fees for the provision of enhanced services that had not been provided. A five figure sum has been repaid to the HSCB while the investigation into potential criminal charges is ongoing.


Counter Fraud Services Counter Fraud Services deliver a specialist fraud investigation capability to its clients. With effect from September 2010, the remit of CFS was extended to cover the investigation of all cases of potential or suspected fraud across all Health and

Social Care organisations. All investigations are required to comply with a range of legal requirements, including those specified in the Police and Criminal Evidence (Northern Ireland) Order 1989, the Criminal Procedure and Investigations Act 1996, The Regulation of Investigatory Powers Act 2000 and the Human Rights Act 1998. A formal criminal investigation can involve staff in a range of specific tasks, including:

Detailed analytical work; Authorised covert surveillance (as regulated by RIPA 2000); Taking of formal witness statements; Taped interviews under caution; Use of forensic services – for imaging of computer hard disks; Preparation of formal evidential packages for submission to PSNI; Co-ordination of interested parties – BSO Directorate of Legal Services,

DHSSPS, Trusts, clinical professionals and outside agencies such as PSNI, UK Border Agency and Identity and Passport Services.

Fraud Investigations During 2010/11, CFS investigated or provided advice in relation to some 128 cases.

17 investigations were undertaken in the secondary care area, covering potentially fraudulent mileage claims and timesheets and the taking of HSC assets for personal use.

C CFPS continues to work closely with the PSNI in identifying and compiling evidence in relation to a number of serial offenders, who are involved in the theft and/or alteration of prescriptions in order to obtain prescription medication to which they

are not entitled, for personal use or for re-sale. CFPS was involved in 55 joint investigations with the UK Border Agency regarding individuals who were illegally in Northern Ireland. In the 55 cases, some 90% of the individuals were found to have been illegally resident in the country and had accessed free health service treatment, which they should have paid for. Details of the cases where individuals had illegally accessed free healthcare treatment were forwarded to the relevant Trusts in order for invoices to be issued, (HSC Board for primary care services obtained). Where these invoices remain unpaid and the person is removed from the jurisdiction by UKBA, they will not in future be allowed to enter the country, even should they hold the correct documentation, unless the previously identified Health Service debt is paid in full. During the 2010/11 year 17 cases were forwarded to the PSNI for further investigation, 8 cases have been passed to the PPS for consideration of legal proceedings and two cases have been successfully prosecuted and convictions obtained.

This is a case of alleged anti-competitive behaviour by a pharmaceutical company.

CFPS has been working closely with colleagues in the UK to instigate civil proceedings for the recovery of related losses from the company in question.

Operation Lexus



27

74

178 2

0

20

40

60

80

Ongoing Closed PSNI PPS Prosecuted

21%

58%

13%6%

2%

Ongoing

Closed

PSNI

PPS

Prosecuted

2010/11 Investigation Outcomes Source of Referrals

HSCB 2

HSC Trust 17

BSO 1

PHA 1

FPS Practitioners* 38

UKBA 55

Whistleblower 6

Other 8

TOTAL 128

*GP/Pharmacy/Dental/Out of Hours

Classification of Referrals

Customer 102

Contractor 3

Practitioner 6

Staff 13

Other 4

TOTAL 128

Status of referrals

Ongoing 27

Closed 74

With PSNI 17

With PPS 8

Prosecuted 2

TOTAL 128

1.5%

13% 0.75%0.75%

30%43%

5%6% HSCB

HSC Trust

BSO

PHA

Primary Care

UKBA

W'blower

Other

80%

2%5%

10%3%

Customer

Contractor

Practitioner

Staff

Other

102

3 613

4

0

20

40

60

80

100

120

Customer Contractor Practitioner Staff Other

2

17

1 1

38

55

6 8

0

10

20

30

40

50

60

HSCB HSC Trust BSO PHA Primary Care

UKBA W'blower OtherFPS Practitioners



Probity Services With the BSO having previously made the decision to deliver Probity Services from 2 locations (Gransha Park House, Derry and Pinewood Villa, Armagh), 2010/2011 saw the establishment of the new Probity Team, with an extensive period of both

„in-house‟ and „hands on‟ training provided by more experienced members of staff and HSCB Clinical Advisers.

Contractor Verification and Assurance The 2010/11 year saw the introduction of robust governance and reporting procedures with the reconfiguration of the 4 Counter Fraud and Probity Sub Groups and the Regional Oversight Group. One of the main objectives of the Probity Team during the 2010/11 year was to

work collaboratively with HSCB staff to finalise the new harmonised approaches in each of the 4 areas. Discussions took place throughout the year as the team worked in conjunction with the Advisers to tackle the issues which arose as the new processes were being implemented.

General Medical Services In terms of General Medical Services the team were tasked with carrying out verification visits to 40 GP practices. Over the 12 month period the team met this target with 40 practices being checked. This work involved carrying 48 practice visits as some practices required more than one visit to complete the checking process. During the 2010/11 year there was also a concerted effort from Probity staff and HSCB Advisers to deliver a „Probity Awareness‟ presentation to GP practices. Over the period this presentation was delivered to approximately 80% of legacy Southern Board practices and approximately 25% of legacy Northern Board practices. It is hoped that the presentation will be delivered to the remaining practices during the 2011/12 year.

Ophthalmic The targeted number of Ophthalmic contractors (50 for the year) has also been met by the Probity Team with 59 contractors having been checked in 2010/11.

Probity Services Ophthalmic The targeted number of Ophthalmic contractors (50 for the year) has also been met by the Probity Team with 59 contractors having been checked in 2010/11. Only 6 of these contractors required a follow up visit with 4 of the 6 having received the revisit during the 2010/11 year.

Dental 2010/11 saw the HSCB agree to suspend the Claims to Records Checks (CRC)

which allowed the Probity Team to focus solely on the newly agreed Dental Probity Assurance Process. The Probity Team was again successful in meeting the SLA target of 80 dental contractors to be selected for a record review. During the year 99 dental contractors were selected for the verification process with 78 of these reviews being completed and closed within the year. Of the remaining 21 reviews 17 of these were ongoing at the year-end as the team carried out further checks and 4 had still to be started.

Pharmacy Of all 4 FPS areas the Probity Assurance Process in respect of pharmaceutical payments is least developed. With the establishment of the new Probity Team the first challenge to the team was to carry out a „Risk Assessment‟ of the different types/areas of pharmaceutical payments. This work was completed towards the end of the 2010/11 year and proposals were put forward and agreed for 2011/12. These proposals will be pilot tested in the 2011/12 year. In addition to developing new processes the Probity Team also delivered a series of checks across a number of pharmacies. These checks were carried out using Patient Checking Clinics with a requirement under the 2010/11 SLA to check between 6 and 12 pharmacies during the year. In total 13 pharmacies were checked, which again exceeded the targeted number.



0.00

5,000.00

10,000.00

15,000.00

20,000.00

25,000.00

30,000.00

GMS Dental Ophthalmic Pharmacy

Recoveries Secured

Monies Recovered

0

20

40

60

80

100

120

GMS Dental Ophthalmic Pharmacy

SLA Target

Delivered

2010/11 Probity Outcomes

SLA Target Delivered

GMS 40 40

Dental 80 99 (78 completed)

Ophthalmic 50 59

Pharmacy 6 - 12 13

Recoveries Secured Monies Recovered

GMS 27,688.73 21,635.85

Dental 29,512.87 29,486.82

Ophthalmic 229.06 175.16

Pharmacy 8,238.40 4,113.40

TOTAL 65,669.06 55,411.23



Patient Exemption Verification Counter Fraud and Probity Services carry out a range of both random and targeted checks, where patients have claimed to be exempt from paying the relevant statutory Health Service charge(s). These checks cover exemptions from both dental and ophthalmic treatments, the prescription charge having been abolished in Northern Ireland on 01 April 2010. Patient information is bulk checked with relevant agencies to verify entitlement. Where patients have falsely claimed exemption from charges, the sums are required to be repaid and, where applicable, Fixed Penalty and Surcharges are applied.

CFPS continues to manage the HSC Charges Advise Line providing customers and Family Practitioner contractors with guidance and information on entitlement. Patients who are entitled to exemption from charges are encouraged to continue to claim correctly.

Risk Measurement

Each year the BSO Information Unit independently calculates the estimated level of patient exemption fraud in Northern Ireland. The calculations are based on the results from a statistically random sample of exemption checks carried out by CFPS. The methodology and resulting calculation are subject to rigorous and detailed scrutiny by external auditors. The „best estimate‟ for the level of patient exemption fraud for 2010/11 was £2.2m.

Patient Charges Advice Line 0800 587 8982

£2.2 million could pay for 350 new incubators.


Working in co-operation with the UK Border Agency, a married couple who were residing unlawfully in Northern Ireland were investigated for fraudulently obtaining non-emergency Health Service treatment to the value of £10,000.


Healthy Start Scheme CFPS administers the NI component of the national Healthy Start Scheme. The overall budget for Northern Ireland for 2010/11 was some £3.7 million. The Scheme has two principal elements:

Healthy Start Vouchers

Vouchers received by relevant beneficiaries and can be exchanged in registered retail outlets for milk or instant formula, plain fresh/frozen fruit and vegetables. The BSO verify and process invoices for the Northern Ireland share of the Scheme costs.

Day Care Foods CFPS is responsible for the reimbursement of claims from registered nurseries and childminders for the supply of milk to children under the age of 5. There were 534 clients registered under the Scheme and during 2010/11 some 1725 payments were made totalling £498,804.52.

£2 million could fund the Day Care Food Scheme for 4 years.


A senior member of Admin staff was investigated for fraudulently submitting travel and subsistence claim forms to the value of £12,000.


Policy and Fraud Awareness

The main remit of CFPS Policy Services is to lead on the production and implementation of policies to support the requirements set out in the Departmental Counter Fraud Strategy (Oct 2005), and to manage the delivery of a

range of fraud and probity support services, including fraud awareness and fraud reporting.

Developing the framework

In July 2010 a draft Sanctions & Redress policy was produced. This document was discussed with key stakeholders and is currently awaiting comment from HSCB Senior Management Team.

An Overseas Visitors Working Group was set up in July 2010 to develop a

regional protocol which sets out procedures to be followed when overseas and cross-border visitors access secondary care provision in Northern Ireland. A number of meetings have since taken place to facilitate the concerns and difficulties faced by Trust Staff. These meetings have resulted in DHSSPS agreeing to develop an advice leaflet and poster to help clarify the process to be adopted by Trusts.

In August 2010 CFPS Policy staff were involved in developing a protocol for use by HSC organisations for the referral of cases to CFPS for

investigation.

In September 2010 CFPS policy staff acted as lead in the co-ordination of the National Fraud Initiative for all HSC bodies.

A Fraud Liaison Officer (FLO) workshop was held in October 2010. CFPS investigators were in attendance in order to meet the FLOs and answer any queries. The investigators outlined the route that should be followed in any instance of suspected or potential fraud and presented, by way of scenarios, examples of different types of fraud that can take place. These scenarios also highlighted some indicators that might alert suspicion that fraud had taken place, and detailed how these might be investigated and the action that could be taken to prevent them. It is planned to continue to hold such events on a bi-annual basis.

Policy and Fraud Awareness

In November 2010 the Trust Counter Fraud Sub-Group was reconvened to discuss secondary care concerns relating to fraud/suspected fraud. Meetings took place throughout the year on a quarterly basis. l Fraud Awareness

A Counter Fraud & Probity Oversight Group was set up in November 2010 to oversee probity and counter fraud work undertaken in Primary Care and to act as a focal point for the resolution of fraud and probity issues relating to primary care. The group is chaired by the HSCB Director of Integrated Care and meets on a quarterly basis. The Terms of Reference of the Group are:-

o Review reported progress on SLA performance by counter fraud and probity service;

o Provide direction/guidance on substantive issues (of significant impact for primary care);

o Agreement and oversight of delivery of work programmes for sub-groups;

o Fraud and probity policies – provide direction/approval for implementation.

In March 2011 Policy staff organised training in respect of the Bribery Act

in association with CIPFA for all CFPS staff and Fraud Liaison Officers for HSC bodies. Follow up guidance issued has been circulated to all

attendees along with a proforma risk assessment template.

Work has commenced to review the MoUs currently in existence between CFPS and external organisations.

Work is also underway with the Department to develop “Directions” to

HSC Organisations in terms of their responsibilities in countering fraud.



Fraud Awareness

During 2010/11 fraud awareness posters and desk-aids were produced and distributed to Fraud Liaison Officers for onward circulation to staff within each HSC organisation. A range of supplementary promotional items were also produced and these items will be distributed at fraud awareness events at key sites planned throughout 2011/12. A small number of fraud awareness presentations were delivered to Audit

Committees towards the end of 2010/11. These presentations will continue through 2011/12, the purpose being to assist all HSC organisations in fulfilling their responsibility to provide fraud awareness training to all staff. A working group was established with key stakeholders to develop a regional fraud awareness e-learning programme. The programme was piloted in January 2011 with a regional roll-out planned for summer 2011/12.

Fraud Reporting With the organisational change brought about by RPA, responsibility for fraud reporting arrangements have been moved to CFPS from DHSSPS. Working closely with stakeholders and BSO ITS, it is proposed to use INFRA software to deliver the necessary reporting functionality. It is planned to roll out new fraud reporting arrangements in September 2011. CFPS continues to manage the HSC Fraud Reporting Hotline which allows members of the public or HSC staff to report a suspicion of fraud anonymously. Further fraud reporting tools are currently in development, including a new online reporting form which will be accessed via the re-launched BSO corporate website.

Fraud Reporting Hotline 0800 096 33 96


A patient who made repeated attempts to fraudulently obtain prescription medication was prosecuted, receiving a two year probation order and two year suspended sentence.

£10 million could pay for over 300 kidney dialysis machines.


Working together. Achieving more. CFPS recognises the value and importance of collaborative working as the development of successful partnerships helps to plan and shape effective strategies to tackle fraud within Health and Social Care.

Fraud Liaison Officers During 2010/11 a network of Fraud Liaison Officers (FLOs) was established covering each of the HSC organisations. Individual meetings with each of the FLOs were held during June/July 2010. The purpose of these meetings was to promote the extended role of CFPS in the delivery of a professional service across the HSC to prevent, deter and investigate fraud and to agree the proposed roles and responsibilities of a FLO. These meetings were welcomed by the FLOs as it gave them an opportunity to discuss any queries/concerns they were experiencing. Fraud awareness posters and desk aids were distributed at the meetings for

onward circulation to staff within each of the organisations.

Four Countries

In November 2010 CFPS hosted the Four Countries meeting. This group consists of representatives from the Department of Health and NHS Protect (England and

Wales), the Scottish Government and NHSS Counter Fraud Service. These meetings are held on a quarterly basis and are hosted by each of the 4 member organisations in turn. The meeting provides an opportunity to discuss issues faced and share ideas and best practices.

Memorandum of Understanding

Memoranda of Understanding demonstrate co-operation between organisations involved in countering fraud and the sharing of data and information in compliance with the Data Protection Act 1998. Work has commenced to review the MoUs currently in existence between CFPS and external organisations.

UK Border Agency

2010/11 has seen the development of very close working relationships with the UK Border Agency in relation to those who are illegally residing in Northern Ireland and their accessing of healthcare.

W

European Healthcare Fraud and Corruption Network Membership of the European Healthcare Fraud and Corruption Network has continued with one member of staff returning from a successful secondment opportunity at the EHFCN Office, Brussels, while CFPS is represented on the Network‟s Standing Operational Committee and participates in a key working group, researching cross-border healthcare fraud issues.

Neville Jones addressing the issues of cross border fraud at the 7th EHFCN Annual Conference.


Recent figures estimate that at least €150 million are lost every day to healthcare fraud and error in the European Union. Make no mistake - we all pay the price for healthcare fraud and corruption and as resources are drained from already restrained health budgets, less funding is available to pay salaries and fund healthcare services and equipment.

“ Paul Vincke, EHFCN President


Going Forward Following on from a year of significant progress, CFPS looks forward to yet more challenging times.

Planned developments in 2011/12 include the launch of a HSC-wide fraud awareness E Learning package, the introduction of an electronic fraud reporting package for HSC client organisations and a major in-house fraud case management system. The Primary Care probity service continues to evolve and develop in order to maximise the contribution it makes to the overall assurance model of the Health and Social Care Board. The Patient exemption verification and the Day Care Foods Reimbursement Scheme will further consolidate the progress they have made since relocation from Belfast to Armagh. The overall vision for CFPS is as a recognised client-focussed provider of high quality specialist services to HSC organisations. 2011/12 offers the CFPS team opportunities to move further forward. This journey will take place against severely constrained financial provision. I both recognise and am grateful for the professionalism, commitment and hard work of the CFPS team during 2010/11 and am confident that this will be the key to on-going progress in 2011/12 and beyond. Neville Jones Assistant Director of Counter Fraud and Probity Services Business Services Organisation

£40 million could build and equip a new health centre.


A Bank auxiliary nurse was investigated for submitting fraudulent timesheets to the value of £50,000.


Annex 1: CFPS Structure



15 Gransha Park Clooney Road

LONDONDERRY BT47 6FN

Tel : 028 7186 0086 Fax : 028 7186 0311

2 Franklin Street BELFAST BT2 8DQ

Tel : 028 9053 5574 Fax : 028 9053 5651

Pinewood Villa 73 Loughgall Road

ARMAGH BT61 7PR

Tel : 028 3741 2744 Fax : 028 3741 2750

www.hscbusiness.hscni.net | [email protected]

Counter Fraud and Probity Services

Business Services Organisation

http://www.hscbusiness.hscni.net/

Documents

Operations Directorate Counter Fraud and Probity Services