Optical contractors

Fraud relating to inappropriate claiming or dispensing at the optical practice, or care provided in homes, nursing, residential or day care facilities.

Optical contractor fraud involves submitting claims to the NHS for optical treatments, services or enhancements which were not delivered or clinically required.

In response to COVID-19, routine eye care was suspended and the optical workforce were proposed for safe redeployment elsewhere in health and social care. There was also the potential of furlough uptake, although hospital optometrists received their normal income. Additionally, to reduce the pressure on GPs and hospitals, some of the workforce were required to maintain urgent and essential eye care. The decrease in the financial vulnerability figure is potentially related to the suspension of routine eyecare.

£38.7m

vulnerable from an expenditure of £225m

In response to COVID-19, practice staff were advised by an optical Standard Operating Procedure (SOP) to remotely triage or risk assess patients unless a face-to-face appointment was essential. However, as appointments were dealt with via telephone there is a realistic possibility that claims were submitted for services which were not actually provided.

It is a realistic possibility that some opticians falsely claimed to have dispensed items or conducted activity to receive a reimbursement/fee as routine services resumed. This could be as a direct result of a temporary suspension in the requirement for patient signatures on electronic General Ophthalmic Services (GOS) forms during COVID-19 or having to meet 40% GOS contributions to maintain income support.

Similarly, some staff may even go as far as to submit false claims for providing treatment to deceased former care home residents. Others may charge both the NHS and the patient for the same private appointment or prescription. However, each month a sample of selected GOS contractors partake in a post-payment verification (PPV) administered by NHSBSA to review the accuracy of claims.

It is likely that as optical contractors return to routine care there will be testing or dispensing irregularities, including dispensing more glasses than required or recalling patients for check-ups sooner than clinically necessary. High reporting has previously been experienced in this area and as opticians are already reporting an increase in sight impairments/loss compared with before the pandemic it may increase again.

Information reports received for optical contractors

The suspension in routine eye care may have inadvertently caused an increase in reporting as those working in optical settings began to develop initiative ways to manipulate the new optical processes. Alternatively, when routine care resumed fraudulent activity may have increased to achieve the required GOS contributions and maintain income support.

33.33%

increase in reporting compared to last year

The change in the number of fraud reports (allegations) received in relation to optical Contractors from 2017-18 to 2021-22: Spend decrease and reporting increase.

2017 to 2018 2018 to 2019 2019 to 2020 2020 to 2021 2021 to 2022
43 47 27 18 24