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How do I…

Dealing with GOS reclaims

AOP head of clinical and regulatory, Henry Leonard, advises practices on how to respond to GOS reclaims in England

form and laptop
Getty/Elena Brovko

NHS England has been actively reclaiming General Ophthalmic Services (GOS) fees from contractors in some areas, where they believe practices have been claiming incorrectly, or over-claiming. Reclaims of this nature typically arise following a Post-Payment Verification (PPV) visit, when the auditor believes there is evidence of incorrect claiming, or where claims have not been properly justified within the clinical notes.

Practices may also be subject to a reclaim attempt if NHS England identifies them as an outlier in terms of their claiming, for example, in relation to prism prescribing without adequate justification.

The audit tool is designed to be as quick and simple to use as possible

 

What should I do if I’ve received a letter from NHS England, proposing a reclaim?

The AOP is aware that in some instances it can be difficult for members to establish if the claims they have made are in line with regulations and that is why we have developed a secure online tool to help them audit their GOS claims.

NHS England should provide a list of any claims they believe are invalid, and practices can then use the AOP’s GOS audit tool to audit these claims, to see whether there is scope to challenge NHS England’s findings. If the audit tool indicates that some of the claims may be valid, members can use this information to challenge the proposed reclaims.

How do I use the AOP’s GOS audit tool?

Once you’ve gathered the clinical records for the claims you wish to audit, you can access the tool by logging into the AOP website.

The audit tool is designed to be as quick and simple to use as possible. At each step of the process, it will try to validate the claim in the simplest way possible and if there is not enough information to justify a claim on the first count, it will ask for more information. It is designed to be as quick and accurate as possible, and only asks for more detailed information where necessary to justify the claim.

How long does it take to audit claims?

This will depend on how many claims you’re auditing and how much information the records contain, but as a guide, it should take around three hours to audit 100 claims.

NHS England may dispute the validity of GOS claims going back up to six years, leading to significant reclaims in some cases. Therefore, it is a good idea for all contractors to make use of the AOP’s GOS audit tool to see if there are areas that they could improve on

 

My practice isn’t currently subject to any reclaims. Do I need to use this tool?

Even if your practice hasn’t yet been audited, we’d recommend using it to perform audits of your claiming periodically, because the tool can highlight areas where your business might be vulnerable to a reclaim in future. For example, GOS4 repair voucher claims are often poorly justified in the records and are a big area of vulnerability for many practices.

GOS1, GOS3 and GOS4 claims can be entered into the audit tool, and, for each type of claim, it will show the percentage of claims that it thinks can be verified from the information contained within the clinical notes.

NHS England may dispute the validity of GOS claims going back up to six years, leading to significant reclaims in some cases. Therefore, it is a good idea for all contractors to make use of the AOP’s GOS audit tool to see if there are areas that they could improve on.

If members have any questions about the GOS audit tool, they can contact the AOP regulatory team by email at [email protected]


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