Post-payment verification process of community pharmacy Advanced Services

Post-payment verification process of community pharmacy Advanced Services

In Autumn 2017, the NHS Business Services Authority (NHSBSA) started undertaking a new post-payment verification (PPV) process of payments to community pharmacy contractors for the provision of Advanced services. The initial focus was on the Medicines Use Review (MUR) service, in early 2018 it was applied to the New Medicine Service (NMS) and in October 2019 the NHS Flu Vaccination Advanced Service was included in the scope of the work.

The PPV process involves requesting evidence from a sample of contractors to support payment claims they have submitted for Advanced services over a specified period.

Click on a heading below for more information.

Background information

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).

What does this mean for contractors?

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.

What is the NHSBSA's process once the forms are submitted?

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.

What do contractors need to do now?

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.

Extension to cover the Flu Vaccination Service

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.

Latest Services and Commissioning news

View more Services and Commissioning news >

PRSB to update pharmacy IT standards

The Professional Record Standards Body (PRSB) previously established Pharmacy information flows IT standards. PRSB are now working with RPS, PSNC,  Community...