Claims vs. Fraud
Although efficiency programs are synonymous with the private sector, they are also been adopted in the public sector. In this regard, the UK government has initiated the Gershon Efficiency Programmes. According to Gorsky (2008) these programmes intend to reduce the costs of healthcare provision, increasing front-line productivity and centralizing procurement services. At the same time the government has undertaken to benchmark the NHS organizations against the performance of their peers. To further enhance the efficiency of the NHS, the government has formed independent bodies such as the Institute for Innovation and Improvement. Through such bodies, the government has been able to introduce new technology in the organization while being able deal with the changes to working practices.
- Fraudulent claims
3.1 Fraud practices by the patients
According to the NHS regulations, low-income patients do not have to pay any charges. However, there are instances, where patients fraudulently avoid such charges. Mandelstam (2006) observes that between 1998 and 1999 losses resulting from patient fraud were €255 m. The extent to which patient fraud is prevalent at the NHS is well captured in an article titled, NHS losing millions to fraudulent patients. According to Mandelstam (2006) there are instances where patients have falsely been claiming travel expenses. There are also instances where patients have been lying to the NHS about benefit entitlement with the intent of claiming free treatment of travel costs. In Scotland, the NHS operations are heavily affected by cases of patient fraud. The administrators are trying their best to investigate fraudulent claims but the process requires a lot of resources.
The situation of fraudulent claims by patients is also captured by an article by Jonathan Owen, an editor with the independent. According to Owen (2014) patients and staff fake invoices, steal money from bank accounts, fake worksheets and fail to pay for prescriptions. There are also situations where patients use false personal details or overseas patients failing to pay for NHS treatment before they leave the country. The total losses resulting from the fraudulent claims are estimated to be £3b, which represents a 3% of the entire NHS budget. According to Gorsky (2008) a lot needs to be done to reduced fraud incidences in the organization
3.2 Fraud patients by the medical professionals
The professionals have implicated, in the fraudulent practices by falsifying exemption claims on prescriptions or failing to submit low value prescriptions to the Prescription Pricing Authority. Medical professionals have also been submitting claims not performed, or overstating such claims. Just to illustrate, dentist are eligible for a ‘recalled attendance’ fee for returning a distance of over one and half miles. In one case that were investigated by the Counter Fraud and Security Management Services, a Liverpool dentist was found guilty of fraudulent claims totaling over £ 7,000 (Gorsky, 2008). Beside the medical practitioners, suppliers are known to bribe employees and managers for awarding of contracts.
3.3 Fraud and corruption by staff
There are instances when non-existing employees have been introduced the payroll and then his or her salary is diverted to the perpetrator. Some of the workers’ also over-state their work hour in order to claim more money. Collusion between the employees and the suppliers is quite common. The employees receive monetary gifts in return to favoring some indentified suppliers. The employees also use the equipment in the workplaces for personal purposes without reimbursing the trust. According to Gorsky (2008) it is also quite common for the employees to alter documents to disguise theft of cash, help the medical professionals to falsify claims or accept cash without declaring it. In one of the cases, a Liverpool NHS receptionist was convicted of false claims (Gorsky, 2008). Hayley Kelly who worked at the Earle Road medical centre was sentenced for six months for falsely claiming sick leave pay. In another case, a domestic assistant who worked for Mersey care was found guilty of taking another job while off sick from the Trust (Gorsky, 2008).
- Fraud prevention and investigation structures
To deal with the cases of corruption and fraud in the organization a number of structures have been established, each of which is discussed below.
- Counter Fraud and Security Management Services
It is a dedicated branch of the NHS which was formed in 1998 with the mandate of reducing fraud to absolute minimum. It was assumed that by reducing fraud cases in the organization, it would free up resources which would then be used for better patient care. The branch ensures resources are well spent and utilized and just to illustrate, in 2010, 105 fraud-related cases were prosecuted. The employees working at the CFSM are well trained as fraud specialists. To operate effectively, the organization has established relationships with the medical practitioners, law enforcement agencies, tax authorities, audit commission, and regulatory bodies (Stewart, 2008).
- Counter fraud specialists
According to Treisman (2007) each of the trusts is required to have an accredited counter fraud specialist. The local counter fraud specialists ensure the NHS resources are used for the intended purpose. They are also mandated to promote a counter-fraud culture among the patients, staff members and the visitors. Upon investigating the alleged fraud cases, they can then take the necessary legal measures. Their responsibility within the fraud-prevention framework is to train the employees how to spot fraud and report suspected incidents.
- Pharmaceutical and dental fraud teams
As indicated earlier, fraud cases are quite prevalent in the pharmaceutical divisions. To deal with this challenge, it is imperative to have a team of specialists who are integrated within the CFMS structure. The specialists propose ways through which fraud cases within the pharmaceutical departments could be avoided.
Mandelstam, M. (2006). Betraying the NHS: Health Abandoned. Jessica Kingsley Publishing
Maureen, L. (2007). Informal Payments and the Financing of Health Care in Developing and
Transition Countries. Health Affairs, 26(4), 23-45
Menzel, D. C. (2005). Research on Ethics and Integrity in Governance: a review and
assessmentPublic Integrity, 7(2, pp. 147–168
Miller, S., Roberts, P. & Spence, E. (2005). Corruption and Anti-corruption: an applied
philosophical approach. New Jersey: Pearson Prentice Hall
Owen, J. (2011). Fraud by staff and patients cost NHS £3bn a year. The independent, 12, 13
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