NHS England and NHS Improvement (NHSE&I) is responsible for monitoring the provision of Essential and Advanced Services by contractors and they have a duty to assure themselves of the quality and probity of activity provided under the Community Pharmacy Contractual Framework (CPCF).

Until the commencement of PPV work by the NHSBSA, this monitoring was the sole responsibility of local NHSE&I teams; however, in many areas resource constraints limited their ability to perform this work, which resulted in a lack of consistency in how this was carried out across the country.

Following a review of internal audits of NHSE&I’s operations, the NHSBSA was asked to pilot a national process for parts of the PPV and performance management of Advanced Services.

This means NHSBSA will do some of the work previously undertaken by local NHSE&I teams; these activities are described as ‘provider assurance’. Taking a standardised and centralised approach to this work means the variability in the way post-payment verification was previously carried out by NHSE&I is removed and all pharmacies will be treated equally and fairly using a consistent, transparent, proportionate and evidence-based approach.

The standardised approach has been agreed by PSNC, NHSE&I and NHSBSA. It aims to identify any issues related to the claiming of payment for Advanced Services and to facilitate resolution of those issues with the individual contractor. Where common issues are identified, advice will be provided to all contractors on how such issues could be avoided in the future.

The new approach operated for a six-month period (which commenced in October 2017) as a proof of concept pilot to establish a centralised approach and evaluate its effectiveness.

The work involved requesting supporting information for Advanced Services payment claims, where NHSBSA already has authorisation to use patient records for PPV purposes (by virtue of the consent statement agreed and signed by the patient receiving the service).

Each month, the NHSBSA requests evidence from a sample of contractors to support the payment claims they have submitted for Advanced Services over a specific period.

The evidence requested will be the signed patient consent forms for the service that correspond to the payment claims made. Contractors will be asked to submit the requested forms with their next monthly prescription bundle.

Contractors are reminded that a consent form signed by the patient is a prerequisite for undertaking MUR, NMS or flu vaccination. These forms include the permission from the patient that they can be shared with NHSE&I, NHSBSA and the Secretary of State for Health to make sure the pharmacy is being correctly paid by the NHS for the service provided.

The process has been designed to be as easy as possible for contractors to provide the evidence; however, if there are any difficulties, NHSBSA are on hand to provide assistance to the contractor.

The NHSBSA review the submitted forms against the payment claims received for the period and will share their findings with the contractor. If there appears to be missing evidence, the NHSBSA will discuss this with the contractor and they will be asked if they can provide alternative evidence that the service was provided.

Once NHSBSA’s findings are agreed with the contractor, information will be shared with the relevant local NHSE&I team. Where necessary, the local team will contact the contractor to discuss the findings. The consent forms submitted by contractors will be returned to them once the NHSBSA has finished reviewing them.

The potential outcomes of the process are:

1. The evidence provided by the contractor matches the submitted payment claims. No further action is required;
2. The evidence provided and the submitted payment claims do not match and the contractor agrees the payment claim was inaccurate and / or an overpayment recovery is appropriate. The overpayment recovery will be made;
3. The evidence provided and submitted payment claims do not match and the contractor believes that the discrepancy may be because of service provision and claims being in different periods (i.e. an Advanced service has been carried out in one month, but not claimed for until a later month). The contractor will be offered the opportunity to provide evidence for a different time period (up to the 12 months within the financial year); or
4. The evidence provided and submitted payment claims do not match (including following outcome 3 above) and the investigation concludes an overpayment has been made based on the evidence available. NHSE&I, via NHSBSA, will notify the contractor of the overpayment recovery and give the option of an appeal.

Contractors may want to review how they currently file signed patient consent forms; if for example, forms are filed alphabetically, by patient surname, a change to filing the forms in chronological order may be worth considering, making retrieval of forms for any specified time period easier, should the pharmacy be selected for participation in this work.

If a contractor is selected by NHSBSA to take part in this work, they will receive a letter which includes full instructions on how to submit the requested consent forms to NHSBSA; only contractors that are contacted by NHSBSA need to submit their consent forms.

From October 2019, the NHSBSA will be requesting evidence to verify payments for the flu vaccination service claimed within the period September 2018 to March 2019.

For the initial sample, the NHSBSA will select contractors that have submitted both digital and paper claims for the service in the same month, with a differing number of total vaccines claimed in the 2018/19 flu season between the two claim methods.

Where there is a need for an overpayment recovery, the value recovered will be that of the lowest price vaccine (plus VAT allowance) that the contractor claimed for during the season, multiplied by the number of payment claims they cannot provide evidence for. The recovery will also include the fees paid to the contractor for those payment claims.

The NHSBSA Provider Assurance team will be sending requests for evidence to the selected contractors by the end of October 2019.

The NHS Business Services Authority (NHSBSA) started undertaking a post-payment verification process for the Advanced Service component of the Pandemic Delivery Service.

In April 2020, a community pharmacy Pandemic Delivery Service was introduced to support those shielding during the initial COVID-19 lockdown. The service was made up of two components: an Essential Service, responding to and identifying those in need of deliveries; and a medicines delivery Advanced Service, for those contractors who delivered dispensed medicines to eligible patients, sometimes on behalf of other contractors. The post-payment verification process only deals with the Advanced Service.

Over a period of nine months the service helped clinically extremely vulnerable patients to shield, where a volunteer was not available to collect medicines on their behalf. Data on the delivery service indicates that over 8,000 pharmacies provided the Advanced Service from its start until December 2020, at a cost of just under £15 million. Pharmacies were asked to maintain appropriate records to support claims and possible post-payment verification of those claims.

The vast majority of payment claims were at levels to be expected from pharmacies. A very small number were higher than might be expected, and NHS England and NHS Improvement (NHSE&I) has decided to scrutinise these. The NHSBSA, which is undertaking the exercise on behalf of NHSE&I, is in the process of writing to the 44 pharmacies identified to date.

While the high claims may be due, for example, to contractor error, they may also be due to a pharmacy undertaking and claiming for the delivery of medicines dispensed by another pharmacy. PSNC has been consulted on the proposed verification process and has sought to ensure the process is appropriately targeted, proportionate and fair to those contractors asked to provide records (as well as fair to the commissioner and public purse).

Contractors may wish to contact NHSBSA to discuss the details of and possible resolution to the verification process. More information on next steps is provided in the letters to contractors. Support can also be provided by PSNC, but contractors are encouraged to liaise with NHSBSA in the first instance.

The Provider Assurance team, part of the NHS Business Services Authority (NHSBSA), has started undertaking a review of Out of Pocket (OOP) expense claims.

The review, commissioned by NHS England and NHS Improvement (NHSE&I), covers OOP expense claims submitted by contractors over two periods, between February 2019 – January 2020, and February 2020 – January 2021. For the two review periods, the Post Payment Verification (PPV) activity has identified a few outlier pharmacies with significantly higher OOP expense claims compared to other pharmacies.

PSNC has been consulted on the proposed verification process and has sought to ensure the process is appropriately targeted, proportionate and fair to those contractors asked to provide records (as well as fair to the commissioner and public purse). The PPV approach for OOP expenses will target a relatively small cohort of pharmacies nationwide having very high values of claims during one, or both of the review periods. The NHSBSA will shortly be writing to a small number of contractors identified with very high values of OOP expense claims, setting out the process for reviewing their claims submitted over the review periods.

Further information

PSNC webpage: OOP expenses

NHSBSA guidance: Submitting your claims for OOP expenses 

Out of pocket expenses claims news article in the Primary Care Bulletin