Dental Contractor Loss Analysis Exercise

Dental Contractor Loss Analysis Exercise A report summarising the results of a loss analysis exercise aimed at measuring the prevalence of suspected fraud in contractor claims within NHS dental services. 31 March 2012 Tackling fraud and managing security

DENTAL CONTRACTOR LOSS ANALYSIS EXERCISE Executive summary 1 This report describes the findings of a loss analysis exercise to measure the prevalence of suspected fraud in contractor claims within NHS dental services England. This work is based upon a random sample of 5000 FP17 dental activity reports for completed treatments drawn by NHS Dental services. All claims were submitted for payment during March 2010. 2 This is the first such exercise undertaken under the current dental contract introduced in April 2006. Since its introduction, NHS dentists have received remuneration according to how many Units of Dental Activity (UDAs) they complete. According to figures obtained from NHS Dental Services, approximately 37.5 million courses of dental treatment were carried out and approximately 83.5 million UDAs were delivered during 2009 10. 3 This report concludes that the estimated loss to suspected contractor fraud during 2009 10 was 73.188m based upon an assessment of resolved treatment queries, with a potential for a further 5.31m of loss in unresolved queries. It is estimated that during this period almost 1 million inappropriate claims (FP17s) were submitted for payment. 4 With revised contract arrangements not expected to be in place until April 2014 these findings indicate that, without intervention, there is an identified risk that a further 146.38million could be lost to fraud whilst the existing dental contract remains in place. 5 The type of suspected contractor fraud was distributed as follows; patient did not receive the level of treatment on the FP17 (50%), split course of treatment (27%), patient did not visit dentist (12%), patient does not exist (10%) and patient paid for treatment but marked as exempt on the FP17 (1%). 2

Treatment bands 6 The current dental contract allows patient treatment to fall into specific charging bands whereby patients pay only one fee for their entire course of treatment, as opposed to individual fees per item of treatment received, under the old system. It also allows dentists to earn Units of Dental Activity (UDAs) for every course of treatment provided, which contribute towards the total quantity of UDAs they must provide, as stated in their service contract, agreed with the local PCT. 7 The current dental contract means that patients pay only one charge for their entire course of treatment. There are four dental treatment charging bands and one for charge exempt services. 8 The exercise examined 5,000 FP17 dental activity reports submitted by dentists to NHS Dental Services for payment during March 2010. 9 All of the bands were represented in the exercise sample. The breakdown of bands in the sample is shown in the table below, which is broadly proportional to the ratio of UDAs claimed by band in the overall population of FP17 dental activity reports submitted by dentists to NHS Dental Services: Band Description of treatment Charge Files Ratio Band 1 Basic treatment (e.g. check up) 16.20 1,100 22.0% Band 2 Mid range treatment (e.g. fillings) 44.60 2,000 40.0% Band 3 Complex treatment (e.g. crowns) 198.00 1,600 32.0% Urgent Urgent or emergency treatment 16.20 228 4.6% Free Charge exempt services 72 1.4% Total 5,000 100% General Dental Services and Personal Dental Services 10 PCTs are responsible for commissioning NHS dental services at a local level, aiming to deliver better access to services, better oral health, an improved patient experience and better working lives for dentists and their teams. They are required to determine the needs of the local population and commission services in line with these needs. PCTs are responsible for contracting with dental practitioners for the delivery of general services under General Dental Service (GDS) contracts as well as entering into local contractual arrangements through the use of Personal Dental Service (PDS) contracts for the delivery of specialised services. 11 It is important that PCTs recognise that there are some dentists who deliver a clinical service beyond what is normally provided under a general service contract by a primary dental care practitioner or who may provide a particular specialism or type of treatment. Suitably experienced dentists can provide a wide range of specialised dental services outside hospital environments and may include services provided by dentists who are on the specialist list of the General Dental Council. 12 PCTs may enter into arrangements with practices which provide specialised services alongside general dental services, or they may be provided as a dedicated service by the entire practice or one dentist. Unless the services were commissioned separately by the PCT, the associated NHS earnings will be calculated by NHS Dental Services. 3

13 Where the entire activity of the practice is not dedicated to a specialised service, PCTs and practices are advised to separate out activity and gross earnings for specialised services, wherever possible through the use of separate contract numbers. Work covered by a PDS contract may not be provided under the GDS by the same provider, nor by any of the performers employed by that provider. Course of treatment and dental treatment plans 14 According to the General Dental Service and Personal Dental Service regulations 1 dentists are obliged to provide mandatory services to a patient by providing to that patient a course of treatment. 15 The regulations also require dentists to provide a detailed dental treatment plan to patients who require treatment above Band 1 level, which must include details of the services which are, at the date of the examination, considered necessary to secure the oral health of the patient. 16 Dentists are not obliged to produce a dental treatment plan for Band 1 level, unless requested by the patient, as the majority of all dental activity is at Band 1 level, and Band 1 courses of treatment are usually completed on the same day the patient is examined. 17 All treatment outlined in the dental treatment plan, including the initial examination, constitutes a single course of treatment attracting a single patient charge and a single FP17 dental activity report. The nature of the dental treatment required determines the banding level. 18 The General Dental Service regulations define a course of dental treatment as follows: (a) a course of treatment, means that: (i) where no treatment plan has to be provided in respect of a course of treatment pursuant to paragraph 7(5) of Schedule 3 (treatment plans), all the treatment recommended to, and agreed with, the patient by the contractor at the initial examination and assessment of that patient has been provided to the patient; or (ii) where a treatment plan has to be provided to the patient pursuant to paragraph 7 of Schedule 3, all the treatment specified on that plan by the contractor (or that plan as revised in accordance with paragraph 7(3) of that Schedule) has been provided to the patient; 19 Dental treatment plans therefore act as a contract between dentist and patient as to the amount, nature and level of dental treatment required and the patient charge incurred, and also acts as an accounting document for when the dentist submits the FP17 dental activity report to NHS Dental Services for payment, in order to support the correct level of remuneration. 1 The National Health Service (General Dental Services Contracts) Regulations 2005; the National Health Service (Personal Dental Services Agreements) Regulations 2005. 4

Units of Dental Activity 20 Since April 2006, NHS dentists have received remuneration according to how many Units of Dental Activity (UDAs) they complete. Each dentist is contracted with the local PCT to provide an agreed quantity of UDAs per year. 21 Individual contract holders UDA values are agreed with the local PCT and so may vary around the country. Usually the more a region is in need of NHS dentists, the more a UDA is worth to the local healthcare economy. However, this is not always the case and two practices in the same street may have totally different UDA values. The current average value per UDA is around 25 but the actual value varies from about 17 to nearly 40 2. 22 The actual cash value of a UDA is set by the local PCT, in discussion with the dentist and/or the dental practice contract holder. Unlike the old dental payment system, the current system of remuneration is based on completed courses of treatment 3, not the number of items in a treatment plan. 23 Each dental procedure has been classified into a specific treatment band which determines how much a patient must pay (unless they qualify for exemption) and the amount of UDAs a dentist earns. 24 During 2009/10, if a dentist performed a basic course of treatment, involving perhaps a routine check up, the patient charge was 16.20 and the dentist was awarded 1 UDA; a mid range course of treatment involving fillings or extractions cost 44.60 to the patient and earned the dentist 3 UDAs; a more complex course of treatment which required laboratory work (such as crowns or dentures) cost 198 to the patient and earned the dentist 12 UDAs. Urgent or emergency dental treatment, usually performed as a rapid response before any further treatments can be scheduled, cost 16.20 (the Band 1 charge) and provided the dentist 1.2 UDAs. Splitting courses of treatment 25 One of the concerns some dentists have with the current system is that UDAs are awarded and calculated for completed treatments regardless of the amount or complexity of work involved. For example, if a dentist provides treatment which involves endodontic work (root canal treatment), that comes under Band 2 level and will earn the dentist 3 UDAs. However, it does not matter if the work is fairly straightforward involving a single upper incisor, or more complicated invasive surgery involving five difficult molars, the dentist will still earn a total of 3 UDAs for that course of treatment. Similarly, if a dentist provides treatment which includes fitting a crown, that comes under Band 3 level and will earn the dentist 12 UDAs. However, it does not matter if the patient needs one crown or ten crowns, the dentist will still earn a total of 12 UDAs for that course of treatment. Some dentists may question why they should earn the same amount of UDAs irrespective of the extent of work they believe to be required, and how they are expected to treat patients with high dental needs whilst still fulfilling their UDA quota. 26 In may be argued by some dentists, that by splitting up single courses of treatment into separate claims for component elements, they can earn the volume of UDAs they believe the work carried out deserves. However, by doing this they would substantially increase 2 NHS Dental Services in England, An Independent Review by Professor Jimmy Steele. 3 Where a course of treatment has not been completed for any reason (for example, the patient fails to return) the dentist will be remunerated for the treatment provided. 5

their UDA levels, thereby improperly reaching their contracted requirements early, and may also unfairly capitalise on patient charge income by charging patients for each stage. Furthermore, dentists having reached their contracted requirements early may then choose not to provide any further NHS dental treatments to their patients for the remainder of the financial year. This may impact upon the equality of dental service provision. 27 Below is an example of how a single course of treatment may be split up into separate claims for component elements, earning the dentist more UDAs than it should. 28 Scenario one shows how the course of treatment should be claimed for; the treatment was written into the patient s treatment plan and was carried out in three stages. The course of treatment commenced on 15/11/2009 and was completed on 10/01/2010 and the highest level of treatment required was at Band 3. Therefore the patient has incurred a single Band 3 charge of 198 and the entire course of treatment has earned the dentist 12 UDAs. Scenario 1 Date Treatment required Band Patient charge UDA value Single course of treatment 15/11/2009 Examination X ray Treatment plan Band 1 13/12/2009 Extraction Root canal 2 x Fillings Band 2 10/01/2010 2 x Crowns Bridge Band 3 198.00 12 UDAs Total patient charge and UDA value 198.00 12 UDAs 29 Scenario two shows how the course of treatment should not be claimed for; the treatment has been carried out in more stages, which commenced on 15/11/2009 and was completed on 07/03/2010. The patient has been asked to return several times, each of the principal stages of treatment has been claimed for separately and the patient charged for each stage. Therefore the patient has paid a total of 501.40 in charges ( 303.40 more than he should) and the entire course of treatment has earned the dentist 31 UDAs (19 UDAs more than it should). Scenario 2 Date Treatment required Band Patient charge UDA value 15/11/2009 Examination X ray Treatment plan Band 1 16.20 1 UDA Split course of treatment 13/12/2009 Extraction Root canal Band 2 44.60 3 UDAs 10/01/2010 2 x Fillings Band 2 44.60 3 UDAs 07/02/2010 Bridge Band 3 198.00 12 UDAs 07/03/2010 2 x Crowns Band 3 198.00 12 UDAs Total patient charge and UDA value 501.40 31 UDAs 30 There are no specific rules forbidding dentists from splitting up courses of treatment into separate claims for component elements, although it does demonstrate sharp practice on behalf of the dentist who earns more UDAs and collects more patient charge income than is necessary. However, if the dentist has already explained to the patient the amount, nature and level of dental treatment required and the patient charge this would incur, and written this into the patient s treatment plan (as they are obliged to do for treatment beyond Band 1), then proceeds to split up the treatment into separate claims and charges, then this may constitute a breach of contract and fraud by false representation and/or fraud by abuse of position (contrary to the Fraud Act 2006). 6

31 The Fraud Act 2006 defines fraud as follows: Fraud by false representation. A person is in breach of this section if he (a) dishonestly makes a false representation, and (b) intends, by making the representation (i) to make a gain for himself or another, or (ii) to cause a loss to another or to expose another to risk of loss. Fraud by abuse of position. A person is in breach of this section if he (a) occupies a position in which he is expected to safeguard, or not to act against, the financial interests of another person, (b) dishonestly abuses that position, and (c) intends, by means of the abuse of that position (i) to make a gain for himself or another, or (ii) to cause a loss to another or to expose another to a risk of loss. 32 Some patients may be aware of dentists splitting up single courses of treatment into separate claims for component elements, and may complain or refuse to pay additional patient charges above and beyond what they believe they should be required to pay (in the above scenario, the entire course of treatment should cost the patient 198 not 501.40). Theoretically, it is therefore simpler and easier for dentists to carry out this practice when the patient is charge exempt, and the patient is less likely to notice or complain as they are receiving a thorough, albeit improperly remunerated, course of treatment. Short recall attendance 33 Historically, dental patients have been encouraged to visit their dentist every six months irrespective of their oral health. However, NICE guidance recommends that patients should be recalled between three months and two years depending on their clinical need. In any event, NICE guidance states the shortest recall for any patient should be three months 4 and PCTs are urged to follow this guidance by monitoring and tackling short recalls in order to deter and prevent inappropriate repeat attendances. 34 As part of the exercise, it was important that short recall attendances be addressed. Following consultation with NHS Dental Services and the Department of Health, it was agreed that there may be logical and clinical reasons for dentists to see their patients again for banded treatment 5 within three months and even within two months of their last visit. However, it was considered to be much more difficult for dentists to be able to explain why they should see their patients again for banded treatment within one month (28 days) of their last visit. 35 In addition to the 5,000 FP17 dental activity reports randomly selected to form the project sample, the exercise also took into consideration a further 363 dental activity reports whereby the patient in the sample had been seen again within 28 days. However this number was reduced since some claims were for urgent treatment or free services and others were for banded treatments provided by different dentists, and therefore deemed to be separate courses of treatment 6. 36 This left 182 additional FP17 dental activity reports for banded treatments performed within 28 days by the same dentist who treated the patient during the visit in the sample. 4 National Institute for Clinical Excellence, Dental Recall, Recall interval between routine dental examinations. 5 Banded treatment means a Band 1, Band 2 or Band 3 course or treatment, as defined in the National Health Service (General Dental Services Contracts) Regulations 2005. 6 See the National Health Service (General Dental Services Contracts) Regulations 2005 definition of entire course of treatment. 7

These additional FP17s were deemed to be part of the patient s course of treatment, and so should be part of a single claim. The fact that separate dental claims were submitted for payment was considered inappropriate. Communication with patients helped determine whether the FP17 dental activity report in the sample or the additional FP17 was the inappropriate one. Participation 37 A total of 5,000 separate FP17 dental activity reports were included in the exercise, each for a different patient. The sample consisted of charge payers and charge exempt patients, adults and children. In total there were 2,941 separate dental contracts and 3,938 individual performing dentists. Wales was not included in this exercise. The breakdown of the sample is illustrated in the following table: Group Category Files Ratio Patient type Charge Payers 2,421 48.4% Exempt Patients 2,579 51.6% All combined 5,000 100.0% Treatment type Band 1 1,102 22.0% Band 2 1,998 40.0% Band 3 1,600 32.0% Urgent / Emergency 228 4.6% Free services 72 1.4% All combined 5,000 100.0% Sample information 38 The Loss Analysis Unit (LAU) requested from NHS Dental Services a random sample of 5,000 FP17 dental activity reports, where treatment had been completed, submitted for payment during March 2010. Additional specifications requested that the sample be for England only, should include both charge payers and charge exempt patients, should include adult patients and children, should exclude dentistry provided to a prison, should not include orthodontic or specialised treatments, and should not feature a patient more than once. 39 Three FP17 dental activity reports were removed from the sample; one record was for a patient who was in prison at the time of the exercise and two records contained insufficient data. This left a sample of 4,997 FP17 dental activity reports for use in the exercise and for loss analysis purposes. 40 Examination of all dental data identified a further 363 FP17 dental activity reports where the patient in the sample had been seen again within 28 days of the FP17 in the sample. Further examination filtered out FP17s for urgent treatment or free services and FP17s for banded treatments provided by different dentists. This left 182 additional FP17 dental activity reports for banded treatments performed by the same dentist who treated the patient during the visit in the sample. These FP17s were taken into consideration during the exercise, but did not form part of the main sample. 8

Interpretation of the data 41 It should be noted that this exercise is based on a sample of FP17 dental activity reports taken from randomly selected dental contract holders only and not from all dental contract holders across England. 42 According to the NHS Information Centre 7, during 2009/10 the ratio of charge paying patients and charge exempt patients was virtually equal, as shown in the following table: FP17s / COTs % UDAs % Charge payers 19,297,000 50.01% 40,886,000 47.84% Charge exempt 19,292,000 49.99% 44,572,000 52.16% Total 38,589,000 100% 85,458,000 100% The sample included 2,421 (48.4%) charge paying patients and 2,579 (51.6%) charge exempt patients, and all exemption categories were represented. 43 Although the sample consisted of FP17 dental activity reports submitted to NHS Dental Services for payment during March 2010, not all were for treatments carried out relatively near that time. A small number of dental activity reports were for treatments carried out in early 2009; it is not known why these were not submitted for payment until March 2010 8. 44 Some dental activity reports had inaccurate details, which made it difficult to trace the patient, cleanse that data and ultimately contact the patient. Activity reports with inaccurate details had to rely solely on the information that was available, unless additional information was provided by the patient when questionnaires were returned. Methodology 45 The LAU traced all but 15 patients (99.7%) in order to verify their existence, to ensure the most up to date contact information was made available, and to confirm whether or not patients had passed away since their treatment. The remaining 15 patients could not be traced. 46 Out of a total sample of 4,997 patients, 4,990 patients were sent questionnaires asking them to confirm the dental treatment they received (questionnaires were not issued to relatives of patients confirmed as deceased). Those who failed to respond were sent a reminder questionnaire; those who failed to respond to that were sent a second reminder questionnaire; those who failed to respond again were contacted by telephone. The LAU achieved a successful response rate of 83.81%, only 808 patients did not respond to any communcations. 47 Each response was carefully assessed and where anomalies arose the patient was contacted by telephone in order to provide further information. Following careful assessment, each case file was classified into one of three file closure groups: 7 NHS Information Centre, NHS Dental Statistics for England 2009/10. 8 Each FP17 dental activity report is associated with a treatment year. A dentist will not earn UDAs in (say) 2009/10 for activity relating to 2008/09. In order that a dentist can earn UDAs for an activity year the dentist must submit the FP17 for scheduling by the time of the June processing, 3 months after the year end in March. This allows the dentist up to 14 months to submit a claim. The dentist may submit claims after June for the previous treatment year, which will be processed by NHS Dental Services but will not count towards year end results. 9

No fraud The patient confirmed that the dental treatment they received and their payment/exemption details matched the details on the FP17 dental activity report submitted by the dentist for payment. There was no reason to suspect the contractor claim was inappropriate. Suspected contractor fraud The patient confirmed that the dental treatment they received and/or their payment/exemption details did not match the details on the FP17 dental activity report. As a result of patient confirmation, evidence was present in the case file which suggested the dentist had claimed for treatment not provided and/or had submitted an inappropriate FP17 dental activity report to the NHS. This suggested a risk of contractor fraud 9. Unresolved The patient was unable to provide confirmation of the dental treatment they received and/or their payment/exemption status; therefore there was insufficient evidence available to make a satisfactory assessment. The LAU was not able to verify the patient s treatment. 48 The table and chart below shows the breakdown of file closure groups: File closure Number Percent of cases No fraud 3,740 75% Suspected contractor fraud 157 3% Unresolved 1,100 22% Total 4,997 100% 49 For the purposes of this exercise, the unresolved cases were analysed separately from the main sample. This makes the assumption that the occurrence of inappropriateness by treatment band in the unresolved cases is equivalent to the occurrence of inappropriateness by treatment band in the resolved cases. 9 The basis on which decisions were made and the burden of proof is that used in civil law the balance of probabilities. This means that each piece of information is weighted against any information contradicting it, and in the context of all the information obtained. The definition of fraud used is the one accepted in civil law, where there appears to be a false statement which, when made, the representor did not honestly believe to be true. 10

50 During the course of the exercise it was possible to examine not only the FP17 dental activity reports in the original sample, but also any other FP17 in the patient s name dated within 28 days before or 28 days after the FP17 in the sample. This meant for every patient in the sample the LAU was able to examine a 56 day period of dental activity (see below). There were 182 additional FP17s for banded treatments taken into consideration. FP17 in the sample 28 days before 28 days after 51 Following confirmation from the patient as to the level of treatment received, an assessment was made to determine whether the FP17 dental activity report included within the sample or the second FP17 was considered inappropriate. For example, if the sample FP17 was for Band 2 treatment and the second FP17 was for Band 3 treatment, and the patient confirmed they received Band 3 treatment, then the FP17 in the sample was considered inappropriate and was factored into the overall analysis. However, if the sample FP17 was for Band 3 treatment and the second FP17 was for Band 2 treatment, and the patient confirmed they received Band 3 treatment, then the FP17 in the sample was considered appropriate; the second FP17 was considered inappropriate but (not being in the sample) was not factored into the analysis. Contractor frauds 52 The following contractor fraud risks were identified during the exercise, all of which have been identified during previous exercises: The patient did not visit the dentist 10 The patient did not receive the level of treatment on the FP17 The patient paid for their treatment but is marked on the FP17 as exempt The patient does not exist / ghost patient 53 There is a further area of suspected contractor fraud risk, which did not exist prior to the new dental contract being introduced in 2006. This is: Split course of treatment Examination of all dental activity for each patient across the entire 56 day period shows some patients received other banded treatments from the same dentist within 28 days of the FP17 in the sample, suggesting that these appointments should come under a single course of treatment. There were 43 instances of split courses of treatment out of 157 fraud risk cases (27.4%). 54 For each of the suspected areas of contractor fraud risk, if sufficient evidence can be obtained 11, the criminal definition of offence is fraud by false representation (contrary to section 2 of the Fraud Act 2006) and/or fraud by abuse of position (contrary to section 3 of the Fraud Act 2006). Both offences incur a maximum penalty of 10 years imprisonment. 10 This includes instances where: the patient did not visit the dentist/practice named on the FP17; the patient did visit the named dentist/practice but at no time on or around the date on the FP17; the patient did not visit any dentist or receive any dental treatment. 11 It should be noted that it is not the responsibility of the LAU to establish intent to defraud to a criminal prosecution standard. Loss analysis exercises examine a statistically valid sample of activity only and suspected fraud risk decisions are arrived at using the civil argument, the balance of probabilities, based purely on the data in hand. 11

Analysis Fraud by false representation. A person is in breach of this section if he (a) dishonestly makes a false representation, and (b) intends, by making the representation (i) to make a gain for himself or another, or (ii) to cause a loss to another or to expose another to risk of loss. By submitting a false FP17 dental activity report to NHS Dental Services, a dentist has dishonestly made a false representation which (a) gains himself a wrongful remuneration and an increased number of UDAs, and (b) causes a loss of remuneration to NHS Dental Services and a loss of UDAs to the commissioning PCT and ultimately to other service users. Fraud by abuse of position. A person is in breach of this section if he (a) occupies a position in which he is expected to safeguard, or not to act against, the financial interests of another person, (b) dishonestly abuses that position, and (c) intends, by means of the abuse of that position (i) to make a gain for himself or another, or (ii) to cause a loss to another or to expose another to a risk of loss. By allowing an employee to submit a false FP17 dental activity report to NHS Dental Services on his behalf, a dentist has abused his position which (a) gains himself a wrongful remuneration and an increased number of UDAs, and (b) causes a loss of remuneration to NHS Dental Services and a loss of UDAs to the commissioning PCT and ultimately to other service users. 55 The analysis comprises all suspected contractor fraud risk types identified during this exercise, including split courses of treatment. 56 The table and chart below shows the reasons for suspected contractor fraud risk: Reason for suspecting a risk of contractor fraud Number Percent of cases Patient did not receive the level of treatment on the FP17 78 50% Split course of treatment 43 27% Patient did not visit the dentist 19 12% Patient does not exist / ghost patient 15 10% Patient paid for treatment but marked as exempt on the FP17 2 1% Total 157 100% 12

57 In addition, 22.01% of cases in the sample were unresolved. For the purposes of this exercise, the unresolved cases were analysed separately from the main sample. This makes the assumption that the occurrence by treatment band of inappropriateness in the unresolved cases is equivalent to the occurrence by treatment band of inappropriateness in the resolved cases. 58 The table and chart below shows the reasons for the unresolved decisions: Reason for unresolved Number Percent of cases Patient contacted but no response received 808 73% Patient contacted but unable to remember 193 18% Patient contacted but refused to assist 48 4% Patient gone away / not known at the address 38 3% Patient deceased 13 1% Total 1,100 100% Numbers do not add up to 100% due to numerical rounding. 13

59 During the course of the exercise the LAU examined not only the FP17s in the original sample, but also every FP17 in each patient s name dated within 28 days either side of the date on the original FP17. 60 It may be the case that a patient requires emergency treatment and is told to return later for remedial work. In this instance there would be a legitimate FP17 claim for 'urgent' treatment and a separate FP17 claim for the subsequent course of treatment. It is therefore possible that two courses of treatment could be justified within 2 months (56 days). 61 It is easier for a dentist to argue the position for the provision of more than one course of treatment within 2 months than it is within 1 month (28 days). Therefore, if there is more than one FP17 during a 28 day period this is more indicative of a split treatment problem and the potential inappropriate delivery of UDAs. The PCT would be in a better position to be able to defend clawing back any payments made for claims made for the same patient within a shorter period. 62 However it should be noted that the 28 days scenario is a way of trying to demonstrate inappropriate claiming on the balance of probability' and has no affirmed regulatory justification. [NHS Dental Services uses the 2 months (56 days) period and multiple FP17s for the same patients submitted within that time period would trigger an exception report to the commissioning PCT. 63 Under the guidance of the NHS Protect Dental Fraud Team, the 28 day period was factored into the analysis in order to detect claims that were submitted within days of each other, which may not have been identified previously. 64 For the analysis, in addition to the overall loss rate, the total extrapolated value of losses was also calculated, as well as the total number of suspected inappropriate FP17s submitted to the NHS for payment and the total number of suspected UDAs lost to the NHS. These calculations were based on the total number of FP17 dental activity reports submitted to NHS Dental Services during 2009/10 and the total number of UDAs delivered. 65 The analysis shows a contractor fraud risk rate of 3.49% with an estimated loss of approximately 73.2 million. Treatment Band Total Number No Fraud Suspected Fraud Band 1 1,099 938 6 Band 2 1,999 1,393 94 Band 3 1,599 1,170 54 Urgent / Emergency 228 181 3 Free Services 72 58 0 Total 4,997 3,740 157 66 According to figures obtained from NHS Dental Services, during 2009/10 approximately 37.5 million courses of dental treatment (COTs) were carried out in England and approximately 83.5 million UDAs were delivered 12, broken down per treatment band as follows ( other includes both urgent treatment and free services): 12 These figures differ slightly from the figures published by the NHS Information Centre, in the report entitled NHS Dental Statistics for England 2009/10. For comparison, the figures published by the NHS Information Centre are attached at Annex 1. 14

Band COTs % UDAs % Band 1 20,044,507 53.4% 20,044,507 24.0% Band 2 11,467,238 30.6% 34,401,714 41.2% Band 3 2,057,367 5.5% 24,688,404 29.6% Other 3,956,465 10.5% 4,381,320 5.2% Total 37,525,577 100% 83,515,945 100% 67 Estimates for the percentage of cases where losses occur were calculated based on the findings of the exercise. These are shown in the subsequent table, along with precision and 95% confidence limits 13 : Band Loss rate Precision ± 95% confidence Band 1 0.66% 0.53% (0.13%, 1.19%) Band 2 5.07% 1.02% (4.05%, 6.09%) Band 3 3.99% 1.07% (2.92%, 5.05%) Other 1.21% 1.39% ( 0.17%, 2.60%) Total 3.49% 0.55% (2.94%, 4.04%) 68 According to NHS Dental Services, the total value of NHS dental contracts in England in 2009/10 was 2,097,417,024 (excluding orthodontic service elements). The total number of UDAs delivered during 2009/10 within the scope of the exercise was 83,515,945 units. This works out at an average cost of 25.11 per unit of dental delivery. Based on these costs, the total loss to the NHS from inappropriate dental contractor claims can be calculated, and the results are summarised in the subsequent table: Band Loss value Precision ± 95% confidence Band 1 3,321,000 2,658,000 ( 663,000, 5,979,000) Band 2 43,806,000 8,846,000 ( 34,960,000, 52,652,000) Band 3 24,728,000 6,612,500 ( 18,116,000, 31,341,000) Other 1,333,000 1,428,000 ( 0, 2,856,000) Total 73,188,000 11,461,500 ( 61,726,000, 86,649,000) 69 The next set of figures are the estimated numbers of suspected inappropriate FP17s submitted to the NHS for payment, for England as a whole: Band Inappropriate FP17s Band 1 127,400 Band 2 724,900 Band 3 90,800 Other 49,000 Total 992,100 13 When measuring fraud, a statistically valid sample of cases is selected to allow us to gain a measure of loss without the need to review all cases in the population. When analysing the results of a measurement exercise, accuracy of +/ 1% with 95% confidence are used to estimate the level of irregularity in the data to a high degree and to tell us about the precision of the statistical estimates. This means that the fraud rate identified in the statistically valid sample has been calculated to within 1% of the total population value, and there is a 95% chance that the fraud rate will lie between the upper and lower confidence limits. 15

70 The next set of figures are the estimated numbers of suspected inappropriate UDAs delivered in England as a whole, which are UDAs lost to the NHS: Band Lost UDAs Band 1 127,400 Band 2 1,772,100 Band 3 966,800 Other 59,000 Total 2,925,300 Summary 71 A summary of the main results is given in the following table for all treatment bands. The first column shows the overall loss rate, the second column shows the overall loss value, the third column shows the number of suspected inappropriate FP17s and the fourth column shows the suspected number of UDAs lost to the NHS. Band Loss rate (%) Loss value Inappropriate FP17s Lost UDAs Band1 0.66% 3,321,000 127,400 127,400 Band2 5.07% 43,806,000 724,900 1,772,100 Band3 3.99% 24,728,000 90,800 966,800 Other 1.21% 1,333,000 49,000 59,000 All 3.49% 73,188,000 992,100 2,925,300 72 It is estimated that for all treatments combined, 3.49% of dental contractor claims were inappropriate. This equates to a figure of 992,100 suspected inappropriate FP17s in England overall, with a loss to the NHS of 73.188 million and a suspected loss of 2,925,300 UDAs. 73 Based upon these revised figures, and using the current value of NHS dental contracts, there is an ongoing risk of loss to the value of 146.38m while the current dental contractor arrangements are in place (which is estimated to be until April 2014). 16

Unresolved queries 74 There were a significant number of unresolved cases in the exercise (1,100 or 22.0%), which included claims for all treatment bands, which suggests that the exercise may be understating the overall level of loss. 75 The main reasons why cases were closed as unresolved were because the patient did not respond to any attempts at communication or they could not remember their treatment. The following table illustrates the unresolved cases per treatment band: Band Cases Band 1 155 Band 2 512 Band 3 375 Urgent 44 Free 14 Total 1,100 76 In order to estimate the size of the potential underestimate, a separate analysis was carried out during which the loss rate from the main sample was applied to the cases in the unresolved category. However, it is important to bear in mind that the majority of unresolved cases were in the higher Band levels, where the highest loss rates were reported and individual contractor costs per UDA vary from contract to contract, so the analysis for unresolved cases therefore introduces a new degree of uncertainty. 77 Having run 10,000 simulations, it was possible to calculate a new estimate including the unresolved cases with associated 95% confidence limits. The results of this analysis suggest that the level of loss in the unresolved category could therefore add an additional 5.31 million onto the previous annual loss figure. 78 The combined results are shown in the subsequent table: Loss value Precision ± 95% confidence Main sample 73,188,000 11,461,000 ( 61,726,000, 84,649,000) Unresolved 5,311,000 824,000 ( 4,487,000, 6,135,000) Total 78,499,000 12,285,000 ( 66,214,000, 90,785,000) 17

Annex 1 79. According to figures published by the NHS Information Centre, during 2009/10 approximately 38.6 million courses of dental treatment were carried out in England and approximately 85.5 million UDAs were claimed, broken down per treatment band as follows: Band COTs % UDAs % Band 1 20,346,000 52.7% 20,346,000 23.8% Band 2 11,700,000 30.3% 35,099,000 41.1% Band 3 2,086,000 5.4% 25,034,000 29.3% Urgent 3,509,000 9.1% 768,000 0.9% Other 949,000 2.5% 4,211,000 4.9% Total 38,590,000 100% 85,458,000 100% 18

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