Data Manipulation fraud

Fraud relating to manipulation of data and the Payment by Results (PbR) system to intentionally falsify performance in order to make a financial gain.

Data manipulation includes falsifying data to meet targets, increase revenue or hide undesirable outcomes. Previously encompassing Payment by Results (PbR) and National Tariff fraud.

However, in response to the COVID-19 pandemic the PbR activity based funding was suspended and replaced by Block Contracts, which continue into March 2022.

£249.1m

vulnerable from an expenditure of £89.9 billion

It is likely that unidentified providers may inadvertently be allocated similar funding to when they were falsifying PbR activity. This could occur as a result of block contract allocation being originally based on a sum equivalent to the provider's historical monthly average expenditure.

There could also be an increase in CCGs overspending without any intent to set up a contingency fund. Under block contract funding, CCGs would be comfortable with the knowledge that their providers can claim additional funding from DHSC.

To avoid surpassing the NHS four-hour maximum waiting time it is highly likely some hospitals may record patients as having been discharged or moved, even though they are still present in A&E. Thus, avoiding detection in the Weekly and Monthly A&E Attendances and Emergency Admissions collection.

Staff with the ability to dispute Key Performance Indicator (KPI) figures increase the risk of the data being manipulated. KPIs are intended to measure whether a service is meeting its contractual requirements efficiently, but they are also an incentive for providers to earn part of their contractual value through targets. Alternative figures may be used to replace the originals and manipulated to meet targets or hide undesirable outcomes.

Additionally, the NHS payment scheme is predicted to replace the National Tariff. On 16/03/2022 the Health and Care Bill encompassing this change was in the report stage within the House of Lords. Once the Bill receives Royal Assent, the NHSCFA and its partners will review and assess the potential threats, vulnerabilities and enablers related to the new scheme. The NHSCFA will also look to assess the threats and vulnerabilities which emerged within the funding packages during COVID-19.

Information reports received for Data Manipulation

Data Manipulation is believed to be underreported to the NHSCFA, potentially because of the complexity of the processes, or the difficultly in distinguishing between fraud and error in the area. The estimated financial vulnerability has significantly increased this year, but cannot be attributed to reporting or intelligence. It has increased as a direct result of an increase in budget and a longstanding loss percentage which is no longer applicable to the area as the structure and processes have changed.

25%

decrease in reporting compared to last year

The change in the number of fraud reports (allegations) received in relation to data manipulation from 2017-18 to 2021-22:

2017 to 2018 2018 to 2019 2019 to 2020 2020 to 2021 2021 to 2022
24 58 13 20 15