3 Recent issues and suggested fixes when dealing CHC retrospective claims

1. PUPoCs delays

In relation to previously unassessed periods of care (PUPoCs), you can request your local NHS Integrated Care Board (ICB) to carry out a retrospective review of healthcare needs to ascertain whether your relative would have been eligible for NHS Continuing Healthcare Funding had they been assessed at the time. The PUPoC review can go as far back as 1^st April 2012. If successful, you will be entitled to reimbursement of the care fees paid during the period of eligibility awarded, plus interest. This can be a substantial sum!

The issue: Since Covid, ICBs have been under the cosh to get their act together and process these retrospective PUPoC reviews more quickly, as there has been a history of ICBs (and the predecessors in name, CCGs and PCTs) dragging their heels and allowing such reviews to drag on for years. So much so, that many claimants sadly passed away years before any (successful) outcome decision was reached. Thankfully, in more recent years, we have noticed a significant increase in the speed most ICBs are turning round these PUPoC reviews…that is, until quite recently.

We have noticed that one or two ICBs have fallen behind again with their PUPoC caseload and are accumulating long lists of cases awaiting review. Delays are usually the result of staff shortages to deal with these particular type of cases (or more cynically ‘financial gatekeeping’). It is too early to tell whether these are isolated ICBs just performing poorly, or whether it is an indication of a wider malaise that is brewing, as ICBs seek to tighten their belts.

The fix: If you are being subjected to unreasonable delay, find out what is the cause and take a view on whether it is reasonable. If not, raise your concerns in writing directly with the ICB and, if appropriate, lodge a formal complaint.

For more background reading:

How to recover care fees paid for unassessed periods of care going back to 2012

2. Proof of payment

If your PUPoC review (or retrospective appeal of a rejected period of care) has been successful, the ICB will write to you telling you with their outcome letter. Their letter will confirm the period of eligibility for CHC awarded and that they are prepared to reimburse care fees paid during this period. The ICB will request that you provide them with documentary evidence of the care fees paid, so that they can process reimbursement. Typically, the ICB will stipulate that they want you to provide copies of all invoices and a statement of account from the care home, and bank statements for the period awarded.

The issue: The ICB might state that you have to provide this proof of payment within a stipulated timeframe, which is usually quite short – say within 30 days – failing which they will consider the request withdrawn and close your case.

So, whilst the ICB might take 12 – 24 months, or indeed longer in some cases, to review your PUPoCs claim (or retrospective appeal), and eventually agree you are entitled to reimbursement, be alert to the possibility of some disreputable tactics.

Whilst elated and relieved with your success, in the same breath, the ICB may try to evade payment by imposing a relatively short deadline to provide them with satisfactory proof of payment before they say they’ll close the case. There is simply no (legal) basis for this! The ICB have spent time assessing the retrospective period under review and have awarded eligibility. There are no time limits. This unscrupulous tactic is both perplexing and grossly unfair and merely adds undue stress and pressure on vulnerable families, who are often represented by elderly or grieving members.

The fix: If an ICB seeks to impose an arbitrary unilateral deadline on you, stand your ground and tell them that they cannot! There is no provision for any such deadline, legal or otherwise, either in their own rule CHC book i.e., the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, the NHS Redress Guidance, or indeed anywhere else!

Ask them to withdraw this arbitrary deadline immediately. Be prepared to complain and, if pushed, do so forcefully. There is simply no authority for such unfair conduct.

To save time and avoid any potential argument with the ICB, we recommend that you get your proof of payment ready as soon as you start your PUPoCs claim or retrospective appeal. Not only will that give you some indication of the expected sum to be reimbursed if you are successful, it will focus your attention on whether it is actually worth your time and effort pursuing the matter in the first place. Secondly, it will help you identify whether there are any gaps in your documentary evidence, so you can make enquiries with the care home or bank in good time and retrieve any missing documents.

Too many successful claimants collate the necessary evidence and then file it away for safekeeping, pending the outcome, but then forget where they’ve put it! Sounds daft, but it does happen quite frequently. So, do keep your evidence in an accessible safe place which you can remember!

Some ICBs are overburdened with bureaucratic ‘red-tape’ and won’t even look at making an offer of reimbursement without you first providing full proof of payment; others will do the calculation in draft but not send it to you until they have seen all the relevant proof (even if it is obvious from the course of pre and post payments made what the missing gap(s) will show). Where an ICB refuses to take a commercial or practical view, such nonsensical stuck-in-the-mud bureaucratic attitudes can create undue delays in processing reimbursement. However, on a positive note, the longer the ICB delays and falls back on its own bureaucratic sword, the more interest is accruing daily on the sum they will eventually have to repay.

For more background reading: How To Recover Care Fees After A Successful Retrospective Review

3. Interest

Having been successful in recovering care fees for PUPoCs retrospective review or an appeal of a retrospective period, the ICB are obligated to reimburse you in full, for the care fees paid during the period of CHC eligibility awarded. The ICB will make an offer of reimbursement and at the same time should provide you with a detailed breakdown as to how they have calculated their offer and applied interest.

The issue: We have come across yet more errors recently in ICB calculations. The last one was nearly £17,000 short of what the client had actually paid (excluding additional interest on top)! This is a significant, eye-watering discrepancy, which has been challenged.

The fix: Don’t take the ICB’s offer and calculation at face value and just assume that it is correct. Whilst invariably it will be correct and errors will be far and few, don’t be the rare exception who gets unwittingly short-changed. You must check the calculation carefully and if this is beyond you, then get professional help. Farley Dwek Solicitors offer a bespoke checking service.

For more background reading:

Don’t be short-changed! Get reimbursed the full amount for your care fees.

Retrospective claims for CHC Funding – are you getting reimbursed the right amount?