Post Payment Verification (PPV) activity for Out of Pocket (OOP) expense claims
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.
Contractors will be required to respond to the NHSBSA by 30th November 2021, confirming their availability to undertake the review by 31st January 2022. NHSBSA will provide a spreadsheet detailing all the OOP expense claims paid to the contractor and ask for confirmation against each that the correct OOP expense claiming process as outlined in the Drug Tariff was followed. To substantiate OOP expense claims, the NHSBSA may require contractors to provide evidence in support of these claims.
As a reminder, pharmacy contractors can claim OOP expense as per Part II, Clause 12 of the Drug Tariff which states:
‘Where, in exceptional circumstances, out-of-pocket expenses have been incurred in obtaining a drug, appliance or chemical reagent other than those priced in Part VIIIA Category A and M, Part VIIIB, Part IXA, Part IXR of the Tariff and all other specials and products not listed and not required to be frequently supplied by the contractor, or where out-of-pocket expenses have been incurred in obtaining from a manufacturer, wholesaler or supplier specially for supply against a prescription, where such expenses on any occasion exceed 50p payment of the full amount may be made where the contractor sends a claim giving particulars to the Pricing Authority on the appropriate prescription form. The endorsement shall be ‘XP’ or ‘OOP’ to indicate that the contractor has taken all reasonable steps to avoid claiming.’
Post Payment Verification
NHSE&I is responsible for monitoring the provision of pharmaceutical 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; PPV is one way in which they undertake this monitoring. The NHSBSA Provider Assurance team undertake PPV on behalf of NHSE&I. Further information on PPV processes can be found on our PPV webpage.