More than 100 patients who underwent dental and eye care treatment in Northern Ireland ended up in court after many were accused of cheating the NHS, a report has revealed.
Dishonesty and mistakes in the system cost the taxpayer just over £3 million (€3.6 million). One GP and two dentists were investigated for suspected fraud, the report revealed. A dentist was referred to the General Dental Council and another faced civil legal proceedings.
The scale of the fraud was disclosed in a paper compiled by Department of Health experts. More than 5,000 cases where exemption from charges was claimed were investigated but only £43,000 was recovered.
Neville Jones, an assistant director at the department's anti-fraud service, said: "Fraud is the theft of health service resources. As such, by any definition or yardstick, it is quite simply wrong.
“Fraud is not a victimless crime and effectively reduces the level of availability of resources for the delivery of patient care.”
People on certain benefits or with some chronic medical conditions can claim exemptions from charges for dental or eye treatment.
During the financial year ending in March, more than 33,000 treatments were checked where exemption from charges was claimed, said the annual report of the Counterfraud and Probity Services Operations Directorate.
This resulted in 5,015 cases being further investigated, and £43,047 was recovered.
A total of 107 cases of suspected fraud or error were won in the small claims court by the health service.
A very detailed and complex investigation led to the successful prosecution last year of two directors of a company delivering mobile eye services. Both were given suspended prison sentences. A repayment of around £40,000 was made to the health board.
Two pharmacies under investigation were also ordered to repay more than £31,500.
Wrongful claims also involved making false declarations to avoid paying for care provided by health service “contractors” such as GPs or to avail themselves of hospital services.
One man who was living abroad but treated in Northern Ireland owed the NHS £27,000. He was married to someone who lived locally, had spent a period in the region and had been registered with a GP, the gateway to hospital services.
He moved to the US but returned for free health care.
Other fraud involved incorrect staff expenses claims - for example nurses who travel to visit ill people in the community may claim for journeys not taken or hours not worked.
Business Services Organisation (BSO) chief executive David Bingham noted a correlation between fraud levels rising and the recession, adding that the service had increased the size of its specialist team.
He said false claims by health service workers themselves tended to start small and then rise as they were not detected immediately, so that patterns could be detected and the perpetrators caught.
He added: “Hours get cut back, people move to part-time working.
“Maybe there is a temptation to put in that extra mileage claim. You do it once and get away with it, but you will get caught.”
The overall bill for health service fraud is around £40 million, he said.
A total of 132 cases were received by the Counterfraud and Probity Services Operations Directorate throughout the financial year ending last March, a quarter involving theft.
The health board reported 56 cases, an increase of 70 per cent on the previous year.
The report said this was due to increased reporting of fraudulent attempts made by individuals to obtain prescription medication, and an increase in the number of cases where individuals were suspected of being resident in the Republic of Ireland but accessing free treatment in Northern Ireland.
A 350 per cent increase in the number of whistleblowing cases was attributed to an increased presence of the fraud awareness team at key health service locations and online reporting, the report said.
Other reasons for investigation can include:
Misstatement of assets when calculating residential care charges to be paid;
Potentially deliberate misstatement of circumstances when claiming social care payments;
Potential misuse of the money of vulnerable patients.
In March the police were investigating 11 ongoing cases and a further seven were with the Public Prosecution Service. In four cases, police gave cautions or other disposals.
Since August 2011, anti-fraud investigations have led to the removal of more than 100 patients from GP registration lists.
In one successful prosecution the person was charged with 18 counts of false representation and sentenced to 200 hours community service for attempting to obtain prescription medication unlawfully.
Checks on one GP raised concerns about potential fraudulent activity, and this case has been referred for further investigation.
Mr Jones added: "Everyone who accesses health and social care services or works to deliver these services has a role to play in tackling fraud.
“If we are to be successful in achieving this, we need to recognise that fraud is wrong and the damage it causes, report it effectively, investigate it thoroughly and professionally and refer to PSNI (Police Service of Northern Ireland) for appropriate action.”
Press Association