Payment Verification

We implement appropriate arrangements for a programme of overall payment verification at both the pre and post payment stages.

Payment verification of the exemption/remission status of patients (patient checking) is now dealt with within a Partnership Agreement between Counter Fraud Services and the NHS Boards.

Payment verification checks will take place on 4 levels:

Level 1 checks are for all claims, as part of the routine pre-payment checking procedures

Level 2 checks involve undertaking a trend analysis and monthly/quarterly sample testing, where:

• The results of level 1 checks indicate that this would be beneficial
• The results of statistical trend analysis indicate a need for further investigation
• The formal assessment of the level of risk associated with a particular payment category indicates a need for more detailed testing

Level 3 checks consist of undertaking extended sample testing and sending out patient letters or conducting a targeted inspection of clinical records. This will be done in order to pursue the outcome of any claims identified at levels 1 and/or 2 as requiring further investigation.

Level 4 involves undertaking a random assessment of claims, which may require an inspection of clinical records and/or patient examination.

Inspection of clinical records may or may not necessitate Practice Visits.