Most dentists would have followed the story of Joyce Trail, a 50 year old Birmingham based dentist, who was convicted of making fraudulent claims in July 2012 after a five-week trial at Birmingham Crown and sentenced on October 5, 2012, by a Crown Court judge to a total seven years of imprisonment.
Trail, who ran Dr Joyce E. Trail & Associates Dental Practice in Hamstead Road, Handsworth, Birmingham was awarded a new NHS GDS Contract in 2006 under the National Health Services Act 1977 by Heart of Birmingham Primary Care Trust but she took advantage of a new way dentists were paid. In April 2006 the payment system changed to what we all know as Units of Dental Activity (UDAs).
Her contract value was between £602-640k per annum, which Heart of Birmingham PCT never queried at the time, given that this contract value would make her one of the highest grossing dentists in the country. Over the next three years she was about to embark on one of the most daring and cavalier operation of its kind in obtaining NHS money and then spending it in style.
She submitted more than 7,000 fake invoices for bogus dental work, including the fitting of false teeth for 120 care home patients who were actually dead. Trail submitted fake invoices for dental work never carried out after carefully targeting elderly care homes in Birmingham and beyond for suitable ‘patients’. A large number of laboratory documents were also processed which simply went unnoticed.
Many readers might not be aware but in 2003 under the old fee per item system, Trail was subject to a claw back of £300k which was paid back to the Dental Practice Board. She claimed that she had misunderstood the system but surprisingly she was not subject to any form of fraud. Trail could have been manipulated into thinking that if caught you could simply negotiate with the PCT and return the tax payer’s money – and not worry about imprisonment or being labelled with fraud.
Fast track to money
For fitting a denture a dentist can claim 12 UDAs - so the more dentures she said she did the more she would be paid. Her monthly FP17s would have detailed the name and procedure carried out but in the absence of monthly scrutiny by the PCT (as all payments made to dentists are on trust) those monthly invoices were settled forthwith. Almost 75 per cent of the payments made to Trail under her NHS contract were based on false claims. The vast majority were for band three work, the highest value NHS dental treatment. She processed 154 claims - costing more than £26k - for fitting dentures or taking impressions for persons deceased at the time she claimed to have started treatment. Trail also claimed for fitting dentures to patients who didn’t need them, for patients receiving private treatment, and doubled and tripled claims for those she had treated.
Extrapolation
Clearly, the NHS went ‘chisel and hammer’ when prosecuting Joyce Trail, but the bigger issue here is that some dentists may not be aware that under a ruling by the NHS Litigation Authority (NHSLA) instigated by Somerset PCT a GDS contractor was subject to an ‘extrapolation sampling’ procedure – which is a form of sampling of treatments carried out against a small proportion of the practice patient base. If it appears that the contractor inappropriately claimed for courses of treatment – then it is likely that the NHS will request that those additional funds be returned.
Previously the NHS dealt with Trail by way of a fine, but now from recently cited examples, it is GDC referred. It is clear to see that the NHS is getting serious and will certainly take no prisoners.
However, extrapolation can be over a lengthy period of time, in the case referred to above, sampling was taken over a four year period which highlighted through the use of a formula that there was possibly a high level of over claiming of UDAs. This sample was then extrapolated to cover activity under the contract. Somerset PCT then claimed that the current debt owed was based on the extrapolated figures and not the actual figures, hence the disparity between what the contractor stated was owed and what the PCT presented as the overpayment.
The key ruling that followed is that the NHSLA determined the PCT was not entitled to claim back money based on the extrapolated sample but rather actual figures, and demonstrating those figures.
Lessons to be learnt
NHS Birmingham and Solihull has begun strengthening its contracting and commissioning process to make sure cases such as Trail do not happen again.
The NHS will further routinely identify and challenge dental practices over unusual or unexpected patterns of treatment. They already have established strong working relationships with the Care Quality Commission and routinely share intelligence on practices.
Principals that engage the services of associates as performers under their contracts should have measures in place – and tightly worded associate agreements, as extrapolation cases can in some instances be true but be carried out by the associates unbeknownst to the principal.
Any dentist that finds that they could be under investigation and/or presented with scenarios as stated in this article, should seek urgent advice from a specialist dental solicitor as a key point to note is that the NHS can be challenged.