Optical contractor fraud
Fraud relating to inappropriate claiming or dispensing at the optical practice, or care provided in homes, nursing, residential or day care facilities.
vulnerable from an expenditure of £499.5 million
Optical contractor fraud involves submitting claims to the NHS for optical treatments, services, or enhancements not delivered or clinically required.
The increase in financial vulnerability of more than double the 2020 – 2021 estimation can be attributed to ophthalmic service activity and associated expenditure returning to normal levels following the COVID-19 pandemic.
It is assessed likely that some contractors will manipulate General Ophthalmic Services (GOS) activity, as well as control and influence other individuals through collusion and co-operation. Fraud can be enabled by submitting false, misleading, or exaggerated claims for treatments not provided or clinically needed. For example, it is a realistic possibility that some contractors may present patients with blank GOS vouchers to sign before any treatment is provided, with prescription details filled in later.
Testing or dispensing irregularities are also present, such as patients recalled earlier than clinically necessary. Some contractors may also carry out 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 in care homes not physically or mentally able to participate properly.
It is likely double income occurs where claims to the NHS are submitted for patients who already paid for private sight tests or glasses. For example, contractors may complete GOS1 vouchers for patients who are part of employer eye care schemes and have sight tests paid by the employer.
Any fraudulent practices to occur within commercial optical chains would be magnified as they are used by more people due to accessibility and size; therefore, creating greater vulnerability to exploitation.
There were 23 reports of ophthalmic contractor fraud this reporting period, an 8% decrease from 2021 – 2022. As such, reporting is 53% lower than in 2018 – 2019, and aside from 2020 – 2021, has also decreased annually. This could be explained by the pandemic disrupting routine health service provision.
However, low-level reporting in this thematic area may be because ophthalmic is the lowest funded and least utilised NHS primary care service, and as such, reporting is proportionately low. Additionally, some claims are processed in batches due to large volume which could result in irregularities being missed.
The change in the number of fraud reports received in relation to optical contractors from 2018 – 2019 to 2022 – 2023 is illustrated in the below chart:
|2018 to 2019||2019 to 2020||2020 to 2021||2021 to 2022||2022 to 2023|
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