SOP 2.3 NHS Making Accurate Claims (England)
Making Accurate Claims
Why do we need to make accurate claims
GOS regulations require that all claims for NHS public funds must be accurate, as far as the information provided allows, to prevent fraudulent claims or overpayment. Local NHS teams audit claims in relation to GOS sight test and optical vouchers. They are legally entitled to inspect records relating to GOS patients which can be a combination of GOS and private records within the period requested. Failure to make accurate claims may result in further investigation of claims, extension of time period of records requested and possibly a fine/reclaim of overpayment.
How often can NHS patients be seen
It is the clinical judgement of the Optometrist to determine how frequently a patient needs a sight test. However, there is a Department of Health (DoH) Memorandum of Understanding (MOU) which outlines the minimum intervals for patient categories of which GOS claims will be accepted.
To accommodate for patient commitment and allow flexibility, the DoH allow a one-month grace period of minimal intervals.
What if a patient presents earlier for an NHS sight test
Patients may be entitled to an earlier sight test if they present with symptoms that require an earlier appointment. In these cases, an early retest code will be required to validate the claim. PCSE England may challenge any claim and ask you to justify your decision. Making clear notes as for the clinical reason for the early sight test that would support this is essential.
Equally important, when at the end of a NHS sight test when setting the recall period, if you require that a patient return sooner than specified for their age or condition category within MOU, you should make adequate notes as to the reason for the earlier recall. Without this, the Optometrist providing the sight test in the future may struggle to justify why they are performing an early sight test.
Important to Remember
It is the presenting symptoms that validate an early test not the outcome of the test. The outcome of the test is never the determining factor of a claim.
For example, if a patient feels their vision has deteriorated since their last test they are entitled to a test. The outcome of the test may be a code 3.2 or 3.3. If there is no change, it is not appropriate to charge the patient. Another example is a patient at the start of the test isn’t entitled to an NHS sight test because their current prescription is under -10.00, Though the results of sights the patient prescription increases to over -10.00, in this case the patient isn’t entitled to sight test. This is because the patient must be eligible for the sight test before the sight test is takes place
What voucher value can I process
Voucher values are determined by patient’s prescription power for more information Click Here
You must keep accurate records of all services and appliances supplied under the GOS and voucher regulations. The Optometrist should always record which GOS 3 voucher they have issued.
There is no statutory definition of fair wear and tear but spectacles for an adult are expected to last two years. Things to consider is (are) scratched lenses, broken frame and basically if the spectacles are beyond repair. Also consider in the case of under 16s if the frames are poorly fitting
Eligibility for a voucher is determined by what the patient requires not the appliance they choose.
If a patient has no significant distance prescription but would like bifocals or varifocals, then a voucher A can be used towards the cost of these. Vouchers E-H can only be used towards the cost if there is a clinically significant distance prescription.
Anti-fatigue lenses, office lenses or enhanced readers are not suitable for a voucher E-H claim. The patient would only be eligible for Voucher A to D in these instances.
Under normally circumstances the patient would only be entitled to a GOS voucher to help with the costs of spectacles to help correct their distance and near vision. However, if you feel it is clinically necessary for the patient to have a third pair of specs to help with their intermediate vision, it is advisable you seek advice from your Regional Team before issuing a GOS 3. If this is approved always record the necessary information on the patients’ records.
Reference Click Here for making accurate claim documents for all the nations.