Data manipulation includes falsifying data to meet targets, increasing revenue or hiding undesirable outcomes, including within A&E. It encompasses the ‘2023 - 2025 NHS Payment Scheme (NHSPS)’ and the four different payment mechanisms it governs within secondary care.
It is possible for appointments to be cancelled at an NHS Trust and then retrospectively booked back onto the system, potentially resulting in funding for services which were not actually provided or to avoid surpassing waiting list time limits.
£165.1m
vulnerable from an expenditure of £55 billion
There is the potential for data to be falsified to appear as if services are continuing to run. Trusts could continue to accept funding for contracted services which they are failing to provide.
The reliance of coding departments on patient notes has the potential to incentivise abuse as coders are restricted to what a clinician has recorded or the information medical staff provide when queried. It is therefore a realistic possibility for treatments to be recorded on patient notes without an appointment taking place. For example, medical staff can record treatments which did not occur, record a different treatment to what has taken place, or genuinely provide unnecessary medical practices to increase revenue.
It is likely for data to be falsified to meet targets or hide undesirable outcomes in secondary care, including to avoid breaching waiting time targets. Alternatively, coders could be instructed or pressured to use a code which incurs a financial return, instead of the actual care pathway which does not.
Information reports received for data manipulation fraud
The change in the number of fraud reports received in relation to data manipulation fraud from 2019 - 2020 to 2023 - 2024 is illustrated in the chart below:| 2019 - 2020 | 2020 - 2021 | 2021 - 2022 | 2022 - 2023 | 2023 - 2024 |
|---|---|---|---|---|
| 2019 - 202037 | 2020 - 202114 | 2021 - 202216 | 2022 - 202313 | 2023 - 20248 |
Horizon scanning
The NHSPS has now been in place for a little over a year and is expected to remain until at least 2025. Also, amendments to the NHSPS were introduced for 2024 - 25 following the NHS England (NHSE) consultation on the NHSPS in December 2023 and January 2024. Therefore, the landscape of fraud may evolve further with additional modus operandi emerging.