NHS England will carry out a six-month trial in Wessex, West Yorkshire and Harrogate as part of efforts to develop a national post payment verification system for General Ophthalmic Services (GOS) claims.
The trial, which begins this month (June), will see the NHS Business Services Authority select a number of GOS contractors each month from the pilot areas using a standardised sampling methodology.
For each contractor selected, the authority will check a sample of GOS submissions against evidence presented by the contractor to ensure that claims are being made appropriately.
According to a national briefing on the scheme, in the event that an inappropriate claim is discovered “a dialogue will be established with the contractor to try and find a way of evidencing the appropriateness of the claim.”
If the claim cannot be evidenced, then the payment will be recovered, the national briefing states.
The national briefing emphasised that the new process aims to provide education and support to help GOS contractors make accurate claims.
The pilot will be evaluated at the end of six months with a view to developing a business case for a national roll out.
AOP clinical director, Dr Peter Hampson, said: “This new pilot from NHS England appears to be a more proportional approach to post payment verification, and has so far taken on board our concerns with the recent processes that caused some of our members a great deal of unease.”
“NHS England has consistently told us that this process is about education and we hope that they are true to their word. The AOP and our colleagues within the Optical Confederation will continue to monitor this process very carefully,” he added.
The new process follows an announcement by the NHS Counter Fraud Authority in January that optical contractors and patients are responsible for £119 million in fraudulent claims each year.
Dr Hampson said that despite repeated requests by the Optical Confederation (OC) to view the report the claims were based on, to date it has not been provided.
The OC remains sceptical of the validity of the report until its members have had the chance to evaluate both the claims and the working contained within the document, he added.