Optical contractor fraud involves submitting claims to the NHS for optical treatments, services, or enhancements not delivered or clinically required.
The increase in the amount financially vulnerable to fraud, bribery and corruption can be attributed to an increase in expenditure.
£94m
vulnerable from an expenditure of £574.6 million
It is a realistic possibility for some contractors to manipulate records to support an inflated or false claim. It is also possible for opticians to continue to make false claims through submitting false General Ophthalmic Services (GOS) vouchers whilst suspended. Some colleagues may assist with the fraud through co-operation or coercion, whilst others who lack professional knowledge may comply with instructions, and unknowingly submit false claims.
It is likely that some contractors have forged patient signatures on GOS vouchers enabling them to submit false, inflated invoices and misleading or exaggerated claims for treatments not provided or clinically needed. Some contractors continue to exploit GOS activity and influence other individuals through persuasion or compulsion.
It is possible for contractors to also be exploiting patient eyesight tests by recalling patients earlier than clinically necessary. Some contractors have the ability to conduct unnecessary sight tests on patients in their own homes by offering unauthorised free home visiting services on the NHS, alongside unnecessary tests on vulnerable patients.
It is likely double income is occurring where claims to the NHS are submitted for patients who already paid for private sight tests or glasses.
It is probable that fraudulent practices will be magnified within commercial chains as they are popular and used by more people due to their accessibility.
It is a realistic possibility for optical contractors to invoice multiple Integrated Care Boards (ICBs) until they receive reimbursement, including through manipulating data to appear as if patients were treated within the system of the ICB they are invoicing.
Information reports received for optical contractor fraud
The change in the number of fraud reports received in relation to optical contractor fraud from 2019 - 2020 to 2023 - 2024 is illustrated in the chart below:
| 2019 - 2020 | 2020 - 2021 | 2021 - 2022 | 2022 - 2023 | 2023 - 2024 |
|---|---|---|---|---|
| 2019 - 202041 | 2020 - 202111 | 2021 - 202224 | 2022 - 202322 | 2023 - 202428 |
Horizon scanning
In January 2024 it became a contractual requirement that all GOS claims should be submitted electronically to Primary Care Support England (PCSE) via the contractor practice management system (PMS). It is likely that this mandatory requirement will deter the number of fraudulent claims being submitted and make it easier for fraudulent claims to be detected.