FRAUDULENT AND inappropriate claims by dentists participating in the publicly-funded Dental Treatment Services Scheme (DTSS) could cost at least €8 million this year.
Senior officials in the Department of Health and the HSE are aware of the potential savings from these claims but have not put the required checks in place to stop privately practising dentists wrongly or over-claiming from this scheme.
A series of unpublished reports commissioned by the Department of Health and the HSE, which detail the extent of inappropriate and fraudulent payments in the system, has been seen by The Irish Times.
The free dental scheme for adults available to medical card holders came to the attention of senior health officials due to the significant extra demand on it during the first eight months of this year.
Higher levels of unemployment in 2008 and 2009 means more people are entitled to medical cards and free dental care.
The August HSE Performance Report shows the scheme provided 30 per cent more treatments than projected up to August 2009. It is also significantly over budget when 2009 spending on the DTSS is compared with 2008.
Expenditure on this scheme was €55 million at the end of August, whereas expenditure for the entire year in 2008 was €65 million. As it is a “demand-led” scheme, the numbers looking for the service are not capped and cannot be controlled.
Dr Paul Batchelor, a London- based oral care consultant who was commissioned by senior officials in the Department of Health and the HSE to assess the scheme, is highly critical of the lack of probity or checks in place to prevent inappropriate payments.
In the most recent report completed earlier in 2009, Dr Batchelor said: “In a system with few if any checks, such as that operated by the HSE . . . a rate probably in excess of 10 per cent would be expected”.
The budget for the DTSS scheme is estimated at €85 million for 2009. Under the scheme, privately practising dentists provide care for medical card holders and claim reimbursement from the HSE for each service provided.
The Department of Social and Family Affairs operates a parallel scheme for those who pay PSRI, called the Dental Treatment Benefit Scheme (DTBS), whereby PSRI contributors are entitled to limited free and subsidised dental care. Under the DTBS, dentists are also paid fees for services provided.
The budget for the DTBS in 2009 is €68 million. If the minimum 10 per cent rate of inappropriate payments is applied to this scheme, a further €6.8 million could be saved this year.
Dr Batchelor, who could not be reached for comment last night, is scathing of the failure of the HSE to put checks in place that could prevent fraudulent and inappropriate claims being made by participating dentists.
In the first report he wrote for the department in 2002, Dr Batchelor recommended a probity assurance scheme be put in place. A system was instigated by the health boards after 2002 but, according to Dr Batchelor, this has been inactive since 2007.
Dr Batchelor’s reports find that most participating dentists are committed and compliant, but there remains significant room for abuse of the scheme due to the lack of information, the failure to monitor activity and the absence of a probity scheme.
The inappropriate and fraudulent payments take the form of dentists who participate in the scheme over-claiming for activity not actually performed or claiming for one treatment when in fact a cheaper treatment was carried out.
The probity scheme for the adult dental plan was a pilot for a probity scheme to be put in place across the public dental, medical and pharmacy schemes. The budget for these schemes in 2009 is estimated at €2.9 billion.