Fraud detection and system improvements in general practice

By Matthew Watson, Medical Partner at Ballards

Having overseen GP Practices for more than 25 years, I’ve witnessed significant evolution in their governance structures. The era of informal management, where a lead partner’s spouse could manage practice records, has long since passed.

Today’s general practice operates in a multifaceted environment, managing diverse income streams from both NHS and non-NHS sources. Practices must navigate relationships with various organisational bodies including PCNs and ICBs, whilst overseeing large workforces comprising salaried GPs, ARRS staff, Physician Assistants, and pharmacists. Additional complexities arise from property management—whether owned or rented—and the challenge of efficient expenditure management.

Given this complexity, instances of process failures and management issues within GP Practices are perhaps inevitable, though surprisingly infrequent. Supporting both personnel and processes is crucial for maintaining practice integrity.

Understanding Financial Risks

When assessing potential financial risks, practices must consider both external and internal threats. This insight focuses on internal threats and their mitigation through improved accounting and financial diligence.

Key Areas of Financial Risk

Financial Misstatement

• Impact on critical decision-making regarding staffing
• Influence on partner appointments
• Effect on service expansion capabilities
• Implications for staff remuneration decisions

Billing Irregularities

• Risk of overbilling
• Billing for non-rendered services
• Upcoding concerns
• Accuracy in service documentation

Asset Protection

• Prevention of cash misappropriation
• Protection of practice assets
• Stock management
• Equipment tracking

Data Integrity

• Protection against unauthorised record alterations
• Maintenance of financial data accuracy
• Audit trail requirements
• Access control measures

Recommended System Improvements

1. Operational Controls

• Implementation of duty segregation
• Enhancement of authorisation workflows
• Regular reconciliation procedures
• Clear documentation requirements

2. Monitoring and Audit

• Scheduled internal audits
• External audit arrangements
• Regular financial reviews
• Performance monitoring systems

3. Staff Development

• Financial compliance training
• Ethics and integrity workshops
• Procedural updates and training
• Documentation of training completion

4. Policy Framework

• Development of comprehensive financial policies
• Implementation of whistleblower protection
• Clear reporting procedures
• Regular policy reviews and updates

The evolving complexity of general practice management demands robust financial controls and vigilant oversight. Whilst instances of process failure remain relatively rare, the implementation of comprehensive safeguards is essential for maintaining practice integrity and financial stability.

Success in fraud prevention and system improvement requires a balanced approach combining clear policies, regular monitoring, and ongoing staff development. By implementing these recommendations, practices can build resilient systems that protect both their financial interests and their ability to deliver quality healthcare services.

Matthew Watson is the Medical Partner at Ballards, specialising in healthcare financial management and compliance.