Payment Verification

Payment verification requirements for general dental services

We operate on behalf of the Scottish Dental Practice Board (SDPB), whose powers are set out in statutory regulations.

We operate a computerised payments system, Management Information and Dental Accounting System (MIDAS), as well as an optical character recognition system called Ident. Both systems undertake extensive pre-payment validation on dental payment claims.

The checks noted below apply equally to paper claims and claims submitted through Electronic Data Interchange (EDI).

We work in close co-operation with the Healthcare Information Group (within the Information Services Division) as the source of statistical advice.

1. Level 1 - The Payments System.

This will automatically carry out level 1 checks for 100% of claims, including:

• Each item of service claimed is code validated and scrutinised against the Statement of Dental Remuneration in respect of the fee, and any provisos or time-limits that apply to it;
• Checking the total value is below the prior approval limit;
• The completion of mandatory fields;
• Duplication of claims;
• Existence of dentist signatures and authorised identification stamp;
• Existence of patient signatures;
• Matching the patient details with the national database;
• Checking the patient’s registration with the dentist;
• Checking the patient's date of birth for age exemption.

Prior Approval

All claims above the prior approval limit require to be submitted for checking before treatment is carried out. These are assessed for both clinical and financial appropriateness.

This level 1 check is equivalent to over 1% of all claims made annually for general dental services in Scotland.

We are currently working on a link between MIDAS and the Community Health Index (CHI), which will further improve checking in respect of capitation payments. It is planned to introduce these at level 1.

2. Level 2 - Sample Check

A minimum 1% sample of contractors will be undertaken in respect of:

• Items of service (risk assessed);
• Patient registration and list size;
• Level of earnings;
• Cost per claim and throughput.

These checks will be based on the findings of trend analysis provided by the MIDAS system and Business Objects.

3. Level 3

Where the outcome of the above checking proves unsatisfactory, or inconclusive, the monitoring team will undertake level 3 checking as appropriate, including:

• Trapping all claims from an identified practitioner, prior to payment, for further assessment;
• Applying the ‘prior approval by targeting’ regulation;
• Applying the ‘special prior approval’ process;
• Sampling patient record cards;
• Detailed assessment of the dentist's prescribing pattern in conjunction with patient histories and record cards;
• Referral of the patient for clinical examination by the Scottish Dental Reference Service to confirm that the treatment was provided.

4. Level 4

We do not carry out practice visits and currently have no powers to do so. However, we do, through the Scottish Dental Reference Service (SDRS), undertake random and targeted examinations of patients.

There are approximately 10,000 referrals made to the SDRS annually, which equates to 0.3% of all claims for treatment for general dental services in Scotland.

The checks undertaken by the SDRS include:

• Existence of patient;
• Confirmation of registration with dentist;
• Confirmation of signature and exemption status check;
• Requirement for items of service (as applicable);
• Provision of items of service;
• Standard of treatment.

Any practitioner who receives an unsatisfactory report from the SDRS, in relation to the validity or standard of treatment provided to their patient, is automatically referred back for assessment at level 3 and will have further cases selected and referred to the SDRS.