THE REASON FOR PROBITY CHECKS
The Health and Social Care Board has a responsibility to gain assurance that payments received by a dental practitioner for health service treatment are fully justified and in accordance with the Statement of Dental Remuneration (SDR).
Undertaking Probity checks does not imply lack of trust in General Dental Practitioners, but is a normal requirement to make available evidence of service provision to support financial reimbursement. The aim of the verification exercise is to gain assurance that claims being submitted are proper and in accordance with the SDR.
Probity Services carry out Post Payment Verification (PPV) of claims from General Dental Practitioners (GDPs) under the guidance of Departmental Circular HSS(F) 46/11.
Probity Services carry out this verification work within a 3 year cycle with approximately 600 dentists checked during each cycle. Once checked a dentist is unlikely to be checked again until the next 3 year cycle.
WHAT HAPPENS DURING THE REVIEW?
The Probity review process normally involves looking at 1 to 3 samples of record cards (each of which may contain a variable number of cards).
Every quarter Dental Advisers will select a number of dentists for a record call based on a review of the payment information or based on other information received by Probity Services. In addition to this a number of dentists may be randomly selected for a record call.
At least 1 item code will be selected as the basis of the initial record call of 10 records. As well as the selected item code all other item codes claimed in the course of treatment will be checked.
Where an item code cannot be assured for payment on more than one occasion in Sample 1, Probity Services will normally seek a second sample of records (usually 20). Checks carried out on Sample 2 will only relate to the item code(s) of concern. Where appropriate, Probity Services may seek comments from the dentist following the review of Sample 1. Any further information provided by the dentist will be considered prior to deciding on next steps (i.e. further sampling, confirming assurance of claims, seeking recovery of non-assured items within Sample 1.
Following the review of Sample 2, Probity Services will contact the dentist to inform him/her of the findings and to seek comments where appropriate. Any further information provided by the dentist will be considered prior to deciding on next steps (i.e. further sampling, confirming assurance of claims, seeking recovery of non-assured items).
Further review(s) of records may be required in order to establish the extent of an issue. However, where Probity Services believes it is possible to resolve a case without having to carry out further sampling it will seek to do so in co-operation with the dentist.
In those cases where a repayment figure has been agreed Probity Services would then arrange to have this deducted from future payment schedule(s).
WHAT IS THE PROCESS?
FREQUENTLY ASKED QUESTIONS
If there is a problem with an item code will I be informed which code it is?
Yes, normally after Probity Services have reviewed a second sample of records. Occasionally, where appropriate, Probity Services will advise the dentist of an issue after reviewing the first sample.
If I am selected for a Probity check do I need to contact my indemnity provider?
This is not normally necessary, however, you may wish to seek assistance from a representative. Most dentists do not normally require assistance from a defence representative.
How does Probity determine whether an item has been assured for payment?
The Dental Adviser reviewing the records against the BSO payment history will seek to establish whether sufficient evidence can be obtained from the record to meet the requirements of the Statement of Dental Remuneration (SDR) and therefore assure the claim/payment. If the evidence is not in the record then the claim cannot be assured for payment. All record entries made must be full, accurate and contemporaneous.
What do I do if I am unsure as to the interpretation of an item code?
The point of contact should be the Probity Services office in the first instance , who will pass your enquiry to the relevant local Dental Adviser. You can contact Probity on 028 9536 2928.
Where an overpayment has been identified how far back in time can Probity Services recover money?
Under the Limitation (N.I) Order 1989 Probity Services can pursue recovery of any monies overpaid over a previous 6 year period.
Can I appeal/contest Probity findings?
If a dentist has any issue or concern with the review findings this should be made clear, preferably in writing, to Probity Services who will then make every effort to resolve this with the dentist. Where issues remain unresolved following discussions with Probity Officers/Dental Advisers, Probity Services will bring for discussion any points or issues raised by a dentist for consideration to the Dental Counter Fraud and Probity Sub Group. However, where matters in respect of recovery of overpayments remain unresolved following discussion at the Sub Group, the HSCB may consider referring the matter under The Health and Social Care (Disciplinary Procedures) Regulations (Northern Ireland) 2014. The Disciplinary Regulations allow for an appeal to be lodged by the dentist in the event that he/she is not satisfied with the outcome of the Disciplinary Committee hearing.
When will I get my records back?
Probity Services will endeavour to return all records in a timely manner. However, the return of records will depend on the outcome of the review(s). Should you require your records urgently please contact the Probity office which issued the letter requesting the records.
- All records must be forwarded to Probity Services within 2 weeks of receiving the request as per Para 25(3)(ii), Schedule 2 of the General Dental Services Regulations (Northern Ireland) 1993.
- Records should be sent by Special Delivery.
- Dentists should ensure that the records are sent to the appropriate office as detailed in the request letter.
- Dentists should ensure that all records requested are submitted. Where this is not the case the dentist should provide an explanation for this.
- Dentists should ensure that all elements of the record are submitted to support the courses of treatment detailed in the Probity letter. This includes all radiological reports, radiographs, chartings (including periodontal chartings - BPEs), lab dockets, photographs etc. Study Models and HS45x forms should only be submitted when requested.
- Dentists should check that all records submitted to Probity Services are returned once the review has been completed. The Probity receipt/ return acknowledgement sheet should be signed and returned once all records have been received back in the surgery.
To reduce the likelihood of any element of a record being lost dentists should ensure that records are contained within wallets/sleeves (i.e. HS49E) of a suitable condition. Computer print outs should be stapled.
Co-operation of practitioners is very much appreciated in the Probity process. We acknowledge that for some practitioners this may be a stressful matter. Probity Services endeavours to minimise any inconvenience and to address any concerns which we encourage you to raise with the Probity office.
In the majority of cases record cards verify the claims submitted and no or minimal recoveries are made, with approximately 90% of initial samples reviewed being assured for payment with no further follow up required.