We are instructed by NHS England & NHS Improvement to request and review evidence to support several different types of claims for remuneration and reimbursement made by Dental Contract Providers.
Purpose of these reviews:
- understand the circumstances surrounding certain FP17 claiming activities
- raise awareness and develop guidance and advice on how to claim
- allow Providers to review and adjust their claiming procedures if necessary
- provide assurance that claims are appropriate
There will be 4 independent exercises starting March 2020.
Across the reviews, the aim is to understand the circumstances surrounding a range of outlier claiming types over a recent time period, with a focus on providing updated guidance and support in as timely and relevant a manner as possible.
Contracts selected for inclusion in the review will be contacted by letter and supported by us to undertake a review of their submitted claims. We expect to have contacted contracts by the end of March 2020.
Providers will be given a 6 month period to review the concern and where necessary implement change (Practice based assurance).
After this 6 month period we will complete a further analysis of contract data to review the concern that was highlighted to the Provider. If in this time the contract rate remains greater than the national rate the contract may be selected to take part in an assurance review. During the review period, the Provider will have the opportunity to review and feedback on our findings.
Where inaccurate claiming is identified, financial recovery and refunds of patient charges may be sought.
The claiming areas included for consideration are:
Incomplete treatments (Band 2 or Band 3)
A review of Band 2 and Band 3 claims submitted with the ‘incomplete’ indicator selected. These claims indicate that a patient began a course of treatment which was not possible to complete.
For example, where a patient fails to attend follow-up appointments.
Dental Contract Providers should make reasonable attempts to contact a patient who fails to attend and should have a practice policy in place to ensure a consistent, fair and transparent process is undertaken when a patient repeatedly fails to attend or cancels at short notice.
Contractors are supported to submit claims at the Band appropriate to the treatment or item started.
The review exercise will aim to confirm that the incomplete indicator is being used correctly and to provide learning and education to Providers if the indicator is being incorrectly applied.
Band 2 fissure sealants
A review of Band 2 claims with only fissure sealant indicated in the Clinical Data Set and no other Band 2 or 3 items present.
We will be looking to assure that the difference between Fissure Sealants and Sealant Restorations are understood and indicated appropriately in FP17 claims.
Band 3 inlays
In May 2018, we wrote to English Dental Contract Providers who had submitted at least one FP17 for the 2017 to 2018 financial year advising them of their rate of Band 3 inlay claims. The letter also confirmed the English national average rate for that period (5.7%).
If Dental Contract Providers have any concerns that their rate of Inlay claiming is either higher or lower than expected, our knowledge base includes advice regarding indirect restorations and associated FP17 claiming.
Band 1 urgent claim followed by Band 2 claim with no examination
We will seek to review contracts with high rates of Band 1 urgent claims that are followed by a Band 2 claim, where no examination is indicated in the Clinical Data Set.
Urgent claims can include the provision of a defined range of treatments following clinical assessment of a presenting complaint.
Banded courses of treatment should always indicate and evidence that a full mouth examination has been provided to the patient. This is to assess oral health and plan the treatment to be provided to the patient.
Where these types of claim are considered as part of a Dental Assurance Review, the review will consider the appropriateness of this pattern of claiming, review the information available to those submitting FP17s and assure that claims are made appropriately.