Patient Exemption fraud

Fraud vulnerabilities relating to prescription charge evasion, dental charge evasion and optical voucher abuse.

Patient Exemption fraud covers a range of abuses within NHS services that require payment upfront in return for access, including within Prescriptions, Dental and Optical. In addition, it covers general fraud conducted by patient’s, such as onward sales of prescribed medication.

During COVID-19 some patients potentially found it easier to falsify symptoms or impersonate another for prescription medications that they did not need. GP surgeries offered limited face to face appointments , instead providing telephone, online and video consultations. Conversely, non-urgent dental care was deferred and routine eye care suspended . The decrease in the financial amount vulnerable to fraud is likely to be correlated with the reduction in routine care.

£214m

vulnerable from an expenditure of £9.6 billion

Patients partaking in the onward sale or supply of prescription medication is highly likely , including via online platforms. Medication may also be sold overseas on lucrative markets.

During the pandemic it is assessed that patients would not have been able to tamper with the electronic prescriptions in comparison to paper ones. The Electronic Prescription Service (EPS) allowed pharmacies to receive prescriptions directly from a prescriber , including after remote consultations.

However, there is a realistic possibility some patients, including repeat offenders, deliberately avoided paying for medication or medical services and remained undetected.

Additionally, it is a realistic possibility that some staff may be confused which benefits qualify. Pharmacy staff are not required to validate or advise on exemption criteria’s, with the responsibility residing with the patient. Therefore, human error continues.

If the consultation to align the upper age for prescription exemptions with the State Pension age is implemented further confusion may be caused. But the expansion of RTEC use and resumption of PECS will improve detection of suspicious exemption claims and potentially deter mis-claimers.

Information reports received for patient fraud

The increase in reporting compared with the previous year is potentially linked to COVID-19 restrictions being slowly lifted and the return to routine care.

The change in the number of fraud reports (allegations) received in relation to patient fraud from 2017-2018 to 2021-2022:

7.14%

increase in reporting compared to last year

2017 to 2018 2018 to 2019 2019 to 2020 2020 to 2021 2021 to 2022
1310 1484 1175 980 1050