Dental Association rejects claims of fraud

The HSE and the Irish Dental Association (IDA) have strongly rejected reports that in excess of 10 per cent of the €85 million budget spent on a dental scheme may be paid to dentists making fraudulent and inappropriate claims. The scheme is known as the Dental Treatment Services Scheme (DTSS).

Fintan Hourihan, the chief executive of the IDA, which represents dentists, said the assertion was “misleading and unfair” while Paddy Burke, of the HSE’s Primary Care Reimbursement Scheme which makes these payments, said he was “satisfied that there is a sophisticated set of controls in place to prevent fraudulent payments”.

The €8 million-plus estimate was contained in unpublished documents on probity commissioned by the Department of Health and internal department documentation as recently as last June. Their contents were reported in last week’s Healthplus. The Department of Health has since posted the report, entitled the 2009 Report on Probity Assurance within the Dental Care Sector on its website.The 10 per cent estimate, or about €8 million, was contained in the report, written by Dr Paul Batchelor, a British-based oral care consultant. It was estimated using international benchmarks for similar schemes and taking into account the vagueness of the contract and the definitions of exactly what work was being carried out by dentists.

Under the DTSS scheme, dentists in private practice are reimbursed by the HSE on a fee-per-item basis, for dental care provided to adults who are medical card holders.

In 2008, 31,526 of the claims made by dentists were not reimbursed. In total last year, the HSE reimbursed dentists for 1,195,945 treatments. The non-payment of claims represents 2.5 per cent of all claims. Up to the end of August 2009, 31,324 claims were not paid, representing more than 3 per cent of all treatments claimed by dentists. This indicates a 0.5 per cent increase in invalid claims between this year and last.

Claims are not paid when “they do not meet necessary criteria for a valid claim”, according to the HSE. Invalid claims can range from a dentist seeking reimbursement for a tooth extraction when that tooth was already extracted, to forms being wrongly completed or unsigned. The HSE was unable to say how much was saved by not paying claims in 2008 or 2009.

Mr Hourihan said “the vast majority of non-payments or refunds relate to forms that are unsigned or filled out in the wrong way rather than being inappropriate or fraudulent claims. Dentists have suffered grievously in the last week as a result of the coverage on so-called ‘dental fraud’.”

The current HSE validation process is a database of all treatments and claims carried out under the DTSS, which is used as a computerised payment process. This system also highlights irregularities in claims. Thirty-two principal dental surgeons investigate irregularities highlighted in the system. These surgeons also validate all complex treatments conducted under the DTSS. Some 9 per cent of treatments carried out, up to the end of August 2009, were these complex, more expensive, treatments. These surgeons do not validate more than 90 per cent of claims.

In addition to the validation exercise, in the past two years, the HSE contacts random patients by letter asking them if they have received specific treatments for which the dentists have claimed. The HSE was unable to say how many of these patients were contacted in 2008 or 2009, but said it was “in the region of a couple of hundred”. It was unable to indicate a response rate for the patients contacted.

Internal documents seen by me show the HSE sought reimbursements from some dentists where surgical extractions were claimed but not actually carried out. The HSE did not respond to questions put to it on this matter.

A Department of Health statement, regarding the estimated 10 per cent rate of inappropriate and fraudulent claims, said: “No specific evidence of inappropriate claims by dentists was contained in the report. The report suggested that apparent weaknesses in the probity arrangements in the DTSS could result in a potential level of disclaiming.”

The department statement also said the HSE was responsible for overseeing probity in the DTSS and other similar schemes. Internal departmental documents also acknowledge the difficulty in proving and retrieving monies associated with fraudulent payments. Fraudulent claims can only be proven if an examining dentist sees patients and all the valid records.

A pilot Examining Dentist scheme whereby patients were examined was discontinued by the HSE early in 2007. Under the current validation scheme, no patients are actually examined as is fundamental to any international, comprehensive probity scheme.

In response to last week’s reports (published in The Irish Times), Minister for Health Mary Harney said she was aware of the problem, but not of the extent of it. She said the HSE should refer to the Garda any data on fraudulent claims that may indicate any fraud in the dental scheme.

Mr Hourihan criticised “the absence of a comprehensive probity scheme, which leaves the overwhelming majority of innocent dentists vulnerable to criticism”. The IDA met the HSE on September 17th “to protest at the continued absence of a dental probity scheme” and was “seeking the restoration of a probity scheme”. Probity schemes are put in place to validate that treatments occur but also as a mechanism for ensuring appropriate and quality care.

Mr Burke acknowledged that “there has not been a system-wide probity assurance scheme in place across the demand-led schemes since the HSE was established in 2005” and added that “a new inspectorate regime has just been put in place”.

According to Mr Burke, the new inspectorate began to operate in recent weeks, starting its work with pharmacies, as “currently 70 per cent of the €3 billion budget for the demand-led schemes is paid out on the pharmacy side”. This new inspectorate has made 15 unannounced visits and 15 planned visits to pharmacies as part of the new inspectorate regime. As a result of these visits, the Garda have been notified in a number of cases, according to the HSE.

It is planned that the new inspectorate will be “rolled out across the 6,000 contractors paid under the HSE’s reimbursement scheme by year end”, said Mr Burke. The inspectorate will cover GPs, dentists, opticians and ophthalmologists, but no work has yet begun on inspecting claims made by these professions.

This article also appeared in The Irish Times, Tuesday 27 October, 2009