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How to maximise your prescription payments in 2021/22

15 July 2021

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FP43 PPA claims expert Daniel Vincent explains why it’s especially important for practices to be on top of prescription claims this year, and advises on how to make sure your practice is claiming all the fees it is due

This article was first published by Pulse Intelligence.

The process of claiming fees for certain drugs prescribed in general practice is confusingly described in many different terms – the ‘FP34’, ‘Personally Administered Items’ or ‘PPA’ claim – but whatever the terminology, its importance in practice profitability is often overlooked.

An estimated £111m of income was unclaimed by practices over the past seven years, and it will be especially important this year to install a robust claims process.

Why now more than ever?

A large chunk of any practice’s FP34 claim will be for seasonal influenza vaccines. Traditionally the annual vaccination program has received income from three sources – reimbursement of vaccine via FP34, the Item of Service (IoS) fee for each vaccination given (formerly through the DES) and the QOF to reward the percentage of patients vaccinated.

However, this year the QOF element has moved from practice level to Primary Care Networks (PCNs) via the Impact and Investment fund. This could adversely impact the income of traditionally high achieving practices if other PCN practices include greater numbers of ‘hard to reach’ patients. Particularly affected are practices within PCNs that contain pockets of deprivation amongst otherwise wealthy areas. The goal of equity is admirable, but practices often rely heavily on the seasonal programme to support nursing team salaries year-round, so this year it will be particularly important to ensure you are picking up as much income from vaccine reimbursements as possible.

What can we claim?

Believe it or not there are over 5,000 items that you can claim for through your FP34 claim. Practically speaking though there are perhaps 20 items that most practices use.

These include the High Volume Vaccines (Influenza, Typhoid, Hepatitis A, Hepatitis B , Pneumococcal, Meningococcal) that the practice purchases directly (rather than ordering nationally supplied stock via Immform). These are claimed using the FP34D form. You simply need to document the number of vaccines used on that form.

Everything else will require an individual FP10 prescription per item. These items include products containing local anaesthetic such as Lidocaine, EMLA cream and Instillagel etc., all injectable products such as Zoladex, Prostap, Depo Medrone, Depo Provera, vitamin B12 and testosterone, all sutures and skin adhesives in Part IXA of the Drug Tariff and coils and ring pessaries, to name a few.  

How can we make a large claim without losing out?

At points during the year, particularly during the flu season or if you are making a retrospective claim for previously unclaimed items, you may have a large amount of items to claim for. In these situations you need to ensure that you split your claim across multiple prescribers to maximise the dispensing fee you receive for each item. Full reimbursement is achieved if each prescriber has less than 461 items to their name each month. Split across your available practice prescribers (anyone with an allocated prescribing code) to achieve this. Don’t forget to count all the FP10s first (you can’t change which prescriber these are allocated to, as it is printed on the FP10) and then allocate the high-volume vaccines appropriately.

Try not to leave claims too long. If you are making a retrospective claim for items not previously claimed, you can go back many years – but you might get a call from your CCG medicines management team due to the in-year budgetary implications. 

Who should complete the FP34 claim? 

In my role I have the pleasure of speaking with several practices a day about their claims process. At the majority, though not all, I hear a similar tale: ‘Well… Phyllis used to do the claim, she just got on with it and did a brilliant job, then she left and it was given to me. We didn’t really have a hand over, I just have these notes. I fit it around my other jobs and barely get time to send off the FP10s let alone run any searches. Some months I miss the deadline so I wait until the next month. I’m going to pass it on to Suzy as soon as I can!’ Sadly, it is one of those roles that most people hate.

However, any other role that was worth an average £4 per patient would be entitled to a trained and passionate individual. You need to search your team for members (ideally two people) who are detail orientated and logical. That person who always asks you ‘why?’ would be ideal. Unlike so many other jobs in general practice, the role can be saved up and completed in bulk so it could be anyone who can be given additional dedicated time. Eight hours a month should cover it.

Successful practices have:

  • A documented process for clinicians to follow that physically prompts them to issue a prescription at point of use.
  • Clinical system searches that are designed to detect items that have been used but no prescription issued.
  • Two trained and time dedicated individuals who enjoy the challenge of increasing practice income through continuous process improvement.
  • Reconciliation of claims made versus claims paid.

The last point is an interesting one. I have never known the NHS Business Service Authority not to pay a FP34 claim correctly. However, keeping a careful record of what is sent and how much you expect to receive is important, not least because it helps the person processing the claims understand how much it’s worth and the real value of what they are doing.

We’re a dispensing practice. Is the process any different for us?

In short no, the same process applies. In my experience the difference a dispensing practice makes is stock control. If your dispensary has tight stock control, ie, nothing leaves the dispensary without a signed prescription, including personally administered items, then you are more likely to be claiming everything. Don’t let this lull you into a false sense of security though. Ask yourself this – do we keep the steri-strips in the dispensary? Most dispensing practices will still keep PPA claimable stock in the Nurse Treatment rooms.

How can we set up a robust process?

You can take the following steps to assure yourself that you are doing everything you can to maximise your FP34 claim.

  • Check your accounts for the previous three years. Based on accountant reports, annual Personally Administered Items income is typically around £4 per patient – and many practices are probably underclaiming.
  • Discuss with the individual making the claim: How regularly are they claiming? Are they doing all of the above? Do they enjoy the job? 
  • Engage an external specialist to review your historical claims and identify missing income.
  • Raise the importance of issuing prescriptions at the point of use with your clinicians at a practice meeting.

Daniel Vincent is an FP34 PPA reconciliation specialist and former practice manager

For more advice and analysis on practice finance and business management topics, visit Pulse Intelligence.