Post-payment verification process for community pharmacy services and activity

Integrated Care Boards (ICBs) are responsible for monitoring the provision of Essential and Advanced pharmaceutical services by pharmacy owners, and with NHS England, have a duty to assure themselves of the quality and probity of activity provided under the Community Pharmacy Contractual Framework; PPV is one way in which this monitoring is undertaken. The NHSBSA Provider Assurance Team (PAT) undertake PPV at the request of NHS England.

Until the commencement of PPV work by the NHSBSA, this monitoring was the sole responsibility of local NHS England 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 NHS England’s operations, the NHSBSA was asked to pilot a national process for parts of the PPV and performance management of Advanced Services as part of a six-month proof of concept pilot to establish a centralised approach and to evaluate it’s effectiveness.

This meant NHSBSA began doing some of the work previously undertaken by local NHS England 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 NHS England is removed and all pharmacies will be treated equally and fairly using a consistent, transparent, proportionate and evidence-based approach.

Following a successful pilot, a standardised approach has been agreed by Community Pharmacy England, NHS England and NHSBSA. It aims to identify any issues related to the claiming of payment for pharmacy services or activity and to facilitate resolution of those issues with the individual pharmacy owner. Where common issues are identified, advice will be provided to all pharmacy owners on how such issues could be avoided in the future.

The work involves requesting supporting information for pharmacy services payment claims, where NHSBSA already has authorisation to use patient records for PPV purposes or supporting information for member claims associated with other remunerated activity.

While PPV processes were put on hold during the pandemic period, NHSBSA have now resumed their activity regarding this work.

Each month, the NHSBSA requests evidence from a sample of pharmacy owners to support the payment claims they have submitted for pharmacy services over a specific period.

In the past, the provision of Advanced services required written patient consent from the patient. As a result, the evidence requested by NHSBSA was the signed patient consent forms for the service that correspond to the payment claims made. As part of contractual changes that occurred in September 2020, it is no longer a requirement that written consent be obtained from patients prior to the provision of services. As a result of this change to verbal consent, pharmacy owners will be asked to submit any required information either electronically, or where a paper record is provided, with their next monthly prescription bundle.

Pharmacy owners are reminded that a record of verbal consent should be made in the pharmacy’s clinical record for the service. Pharmacy owners need to ensure that the patient are made aware that there may be:

• sharing of information about the service with NHS England as part of service monitoring; and

• sharing of information about the service with NHS England and the NHSBSA as PPV.

For the Community Pharmacist Consultation Service, where medication supplies are made in response to urgent medication requests, EPS tokens for exempt patients are  sent to NHSBSA to be scanned and kept for PPV purposes.

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

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

Once NHSBSA’s findings are agreed with the pharmacy owner, information will be shared with the relevant Integrated Care Board (ICB) primary care team. Where necessary, the ICB will contact the pharmacy owner to discuss the findings. Any evidence submitted by our members will be returned where appropriate to them once the NHSBSA has finished reviewing them.

The potential outcomes of the process are:

1. The evidence provided by the pharmacy owner matches the submitted payment claims. No further action is required;
2. The evidence provided and the submitted payment claims do not match and the pharmacy owner agrees the payment claim was inaccurate and / or an overpayment recovery is appropriate. An overpayment recovery will be made;
3. The evidence provided and submitted payment claims do not match and the pharmacy owner 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 pharmacy owner 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. The matter will be forwarded by NHSBSA to the local Pharmaceutical Services Regulations Committee (PSRC) for review. Where the PSRC confirms the NHSBSAs findings, the ICB, via NHSBSA, will notify the contractor of the overpayment recovery and give the option of an appeal.

Cases are referred to PSRC where there is no contact from the pharmacy owner or their representative or the pharmacy owner does not agree that there has been an overpayment.

Read the NHSBSA processes

Pharmacy owners, may want to review how their clinical services IT system allows the appropriate identification of patients who have been provided a service.

If a member 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 evidence to NHSBSA; only pharmacy owners that are contacted by NHSBSA need to submit their evidence.

From October 2019, the NHSBSA began requesting evidence to verify payments for the flu vaccination service.

While this activity was suspended during the pandemic, PPV on vaccinations has since resumed. Members are asked to support requests for evidence from the NHSBSA Provider Assurance Team to allow them to complete PPV checks in line with the requirements in the service specification.

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.

NHSBSA is currently undertaking PPV associated with the various phases of COVID-19 vaccinations provided by pharmacy owners. The phases of PPV activity will correspond to the various phases of COVID-19 vaccination. The timings associated with these activities are listed below:

• Phase 1 – Service payment claims from December 2020 to March 2021 – A total of 244 pharmacy owners had PPV conducted – PPV completed;
• Phase 2 – Service payment claims from April 2021 – August 2021- A total of 58 pharmacy owners were elected for PPV – PPV is currently ongoing;
• Phase 3 – Service payment claims from September 2021 – March 2022 – A total of 105 pharmacy owners were selected for PPV – PPV is currently ongoing;
• Phase 4 – Service payment claims from April 2022 – August 2022 –A total of 66 pharmacy owners were selected for PPV – PPV is currently ongoing; and
• Phase 5 – Service payment claims from September 2022 to March 2023 – PPV is currently ongoing.

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 has decided to scrutinise these. 650 pharmacy owners were selected for PPV. The NHSBSA, which is undertaking the exercise on behalf of NHS England, is in the process of writing to the pharmacies identified to date.

While the high claims may be due, for example, to provider error error, they may also be due to a pharmacy undertaking and claiming for the delivery of medicines dispensed by another pharmacy.

Community Pharmacy England has been consulted on the proposed verification process and has sought to ensure the process is appropriately targeted, proportionate and fair to those of our members asked to provide records (as well as fair to the commissioner and public purse).

Pharmacy owners 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 Community Pharmacy England, but members are encouraged to liaise with NHSBSA in the first instance.

NHSBSA is currently undertaking PPV associated with the various phases of national announcements that triggered commissioning of the delivery service from pharmacy owners. The key element of the PPV for this service is whether deliveries were made to eligible people in line with the appropriate local and national lockdowns and the confirmed commissioning announcements.

Details of each of theses commissioning announcements, can be found in the pandemic delivery service archives . The PPV timings associated with these activity are listed below:

• Phase 1 – Service payment claims from April 2020 to July 2020 – PPV completed;
• Phase 2 – Service payment claims from August 2020 – October 2020- PPV completed;
• Phase 3 – Service payment claims from November 2020 – December 2020 and January 2021 – March 2021 – PPV is currently ongoing; and
• Phase 4 – Service payment claims from April 2021 – March 2022 – PPV to be confirmed.

Since the beginning of 2018 the NHSBSA Provider Assurance team have performed monthly samples reviewing NMS claims made by pharmacies and asking them to send in evidence to support their payment claims. Over 1,500 contractors have had PPV on their NMS activity.

While this activity was briefly paused , during the pandemic, NHSBSA have restarted PPV activity on the NMS. It is anticipated that up to 400 pharmacy owners will be requested to provide evidence associated with their NMS claims.

NMS PPV will then continue for subsequent years, however, it is anticipated that when work is completed between NHS England, NHSBSA and the various pharmacy service IT system providers on an application programming interface (API) to assist with claiming for the service via MYS, that the required information will be automatically available to the NHSBSA to review. This should then reduce the administrative burden on members to supply the associated evidence.

Update April 2024

Selected pharmacy owners have been contacted by the NHS BSA Provider Assurance Team for post-payment verification for NMS activity.

NHS BSA restarted this program of work in June 2023 and sought data from dates 2021/22. As the year has progressed, this has raised concerns from pharmacy owners and Community Pharmacy England, as records for NMS need only to be retained for two years. Having engaged with NHS England, the process has been revised and clarified as follows:

• The year of service activity will be amended to 2022/23, so the pharmacy records should still be available for those accounts that have not yet been contacted.
• A patient’s NHS number is the preferred evidence to confirm the claims were made in accordance with the service specification.
• If the NHS number is not available, enough information should be provided to identify the patient such as the patient’s name, and DOB.
• The range of data requested initially should be one quarter and one other month within the year of service provision as advised by Provider Assurance. Further months may be requested if assurance cannot be achieved from the initial data provided.
• Provision of the data requested is mandatory, as part of the Terms of Service (TOS). Community Pharmacy England encourages pharmacy owners to engage with the PPV process in a timely manner to avoid any escalation to their ICB commissioner for a potential breach of their TOS.

PPV is currently ongoing.

While PQS is not a service, the NHS England guidance for PQS clearly stated that the evidence of meeting the requirements of the gateway criterion and each domain should be retained for two years as it may be required for post-payment verification purposes.

NHSBSA has completed PPV associated with the 2021/22 PQS.  PPV was undertaken on the NMS gateway criterion from PQS 2021/22 on 127 pharmacy owners.

PPV also occurs as part of the Aspiration payment reconciliation process. NHSBSA is current looking at 425 accounts related to this and at 100 pharmacy owners who did not meet the NMS gateway criterion as part of PPV on the 2022/23 PQS.

NHSBSA will also be looking at PPV options regarding weight management and audits for the 2022/23 PQS.

PPV is currently ongoing.

The Provider Assurance team has started undertaking a review of Out of Pocket (OOP) expense claims.

The review, commissioned by NHS England, 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 PPV activity has identified a few outlier pharmacies with significantly higher OOP expense claims compared to other pharmacies.

Community Pharmacy England 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. Where the NHSBSA identifies pharmacies with very high values of OOP expense claims, they will write to them setting out the process for reviewing their claims submitted over the review periods.

Further information

Community Pharmacy England webpage: OOP expenses

NHSBSA guidance: Submitting your claims for OOP expenses 

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

From 9th October 2023, the NHSBSA Provider Assurance Team (PAT), will start to undertake PPV reviews of pharmacy owners providing the Hypertension Case-Finding Service.

The reviews, commissioned by NHS England, will look at the following categories:

• Highest claimers of blood pressure checks;
• High volumes of opportunistic blood pressure checks in those under the age of 40 years;
• Pharmacies with high numbers of clinic blood pressure readings but disproportionately fewer (or no) ambulatory blood pressure monitoring (ABPM); and
• Pharmacies that have reported higher volumes of identified patients with very high clinic blood pressure readings.

Community Pharmacy England has been consulted on the verification process and has sought to ensure it is appropriately targeted, proportionate and fair to those pharmacy owners asked to provide records (as well as fair to the commissioner and public purse).

The process

The initial review period is for claims between October 2022 and December 2022

The PPV approach for the Hypertension Case-Finding Service will begin by targeting a relatively small cohort of pharmacies nationwide having very high volumes over the review period in one or more of the above categories. The NHSBSA will write to the selected pharmacy owners, setting out the process for reviewing their claims submitted over the review period.

NHSBSA will provide a summary, to each selected pharmacy owner, of the number of blood pressure checks that were claimed and ask for the corresponding records that were sent to the patient’s general practice for entry into the patient record. As part of the PPV process, additional information, such as appropriate referrals made etc., may be requested to provide additional evidence to support these claims.

Community Pharmacy England would encourage any pharmacy owners who are selected, to provide the requested evidence of service provision as part of the PPV process and to fully engage with the NHSBSA PAT through the process. The NHSBSA PAT will provide advice and support to pharmacies if they are unsure what evidence is required.

PPV is currently ongoing.

The provider assurance approach for the Lateral Flow Devices (LFD) test supply service will initially begin by identifying a relatively small cohort of pharmacies nationwide with an unexpectedly high volume of claims over the first few weeks of the service going live. 

The NHSBSA will send an email to pharmacy owners which will aim to check their understanding of the service, the checks being carried out on patients’ eligibility, and that they are keeping the necessary records in line with the service specification.  

The email will ask the pharmacy owner four questions: 

1. Does the pharmacy have a standard operating procedure (SOP) in place for the service?
2. Has the pharmacy updated NHS Profile Manager to state that the service is available to eligible patients from your pharmacy? Note that it is a regulatory requirement for a contractor to ensure that there is a comprehensive and accurate pharmacy profile in respect of their pharmacy premises on the NHS.uk website. 
3. Does each patient that requests the service have their eligibility checked? Where a patient’s representative requests the service on the patient’s behalf, the patient’s eligibility should be determined with the representative. 
4. Does the pharmacy retain appropriate records including confirmation of patient eligibility each time the service is provided, for example, in the Community Pharmacy England record form LFD-Record-Form-2023.pdf (cpe.org.uk)? 

The responses will be recorded and used as part of later provider assurance work if NHS England seeks to undertake PPV in response to or in the absence of information received from the pharmacy owner.    

In January 2024, the NHSBSA PAT will engage with around a further 50 pharmacies, broadly one pharmacy per integrated care board (ICB), who appear to be outliers for claims made since the service began. 

After completing these checks and collating results, NHS England will decide whether there is a need for a wider provider assurance exercise of the LFD service.