The PPA Reimbursement Process Explained

Previous

PPA Basics: What and Why?

Introduction

Now that you know what qualifies as a Personally Administered Item (PPA) and why it matters, let’s follow the money. In this article, we break down how the NHS calculates reimbursement for each PPA claim, where those rates come from, and why they can fluctuate month to month. We’ll also cover recent updates on extended claim submission deadlines and a tiered dispensing fee structure that can affect your practice’s bottom line.

(Want to see what sorts of vaccines or injections bring in the most income? See Common PPA Items for a closer look at the major drivers of PPA claims.)

Core Components of PPA Reimbursement

When your practice submits a claim for a personally administered item, the amount paid typically consists of:

1. Basic Price (Drug Tariff Price)

   • The NHS refers to the monthly Drug Tariff or other official pricing sources (like the BNF). This is the baseline “list” cost.

2. Discount (“Clawback”)

   • The NHS assumes you receive a bulk discount from your supplier - so they deduct a set percentage. This percentage can vary depending on total prescribing volumes and government policy.

3. Dispensing/Administration Fee

   • A small fee is added per item, similar to what a community pharmacy would earn. It’s essentially payment for the act of handling or administering the medication.

4. VAT Allowance (if applicable)

   • Many medicines are zero-rated for VAT, but if your practice paid VAT (e.g. on certain appliances), an allowance may be added to ensure you aren’t out of pocket.

5. Additional Fees or Adjustments (occasionally)

   • This might include out-of-pocket expenses for special delivery charges or fees for unlicensed medicines. They’re less common but do exist in certain scenarios.

Monthly Updates & Ongoing Changes

Drug Tariff prices and the discount deduction rate can change regularly. This is especially relevant for:

• Generic injections that might shift in price due to supply issues.

• Seasonal vaccines (e.g., flu) that can differ year to year.

• Branded items (e.g., contraceptive implants, hormone implants) which may have their own evolving list price.

(For tips on sourcing supplies at or below Tariff to ensure you’re not losing money, check out Procuring Stock: How Practices Obtain PPA Items)

Example: A Quick Numbers Run-Through

Suppose you administer an injection priced at £10 in the Drug Tariff, and your practice’s discount rate is 10%:

• Basic Price: £10

• Less Discount: £1 (10%)

• Add Dispensing Fee: ~£1 (exact figure can vary)

• Total: ~£10 - £1 + £1 = £10 net.

If you managed to purchase the injection from a wholesaler at, say, £8.50 per vial, you’d pocket a small margin above your actual cost. Conversely, if your supplier charges more than the Tariff net, you might make less - or even lose money.

(For guidance on when to skip PPA and issue an FP10 instead, see Deciding When to Use Practice Stock vs. FP10.)

Extended Submission Deadlines & Tiered Fee Structure

1. Submission Deadlines: Up to Six Years

• Standard Monthly Cycle: In general, practices aim to submit claims by the 5th of the month following usage to maintain a healthy cash flow and avoid confusion.

• SFE Directions 2024: If you miss that immediate timeframe, you actually have up to six years from when the drug was first used to submit or correct a claim.

  • This extended window (as outlined in the Statement of Financial Entitlements Directions 2024) allows you to rectify administrative oversights - so there are no penalties specifically tied to late submissions within that six-year limit.

  • Why Bother Submitting On Time? Even though the law permits a long backdating period, filing promptly helps you stay on top of finances, avoid backlogs, and reduce the risk of mistakes accumulating.

2. Tiered Dispensing Fees after 460 Items

• What It Means: If a single prescriber (GP or nurse) submits over 460 PPA claims in one month, the dispensing fee per item starts to drop significantly. The NHS Business Services Authority (NHSBSA) uses a sliding scalebased on volume.

  • First 459 (or 460) items: Higher dispensing fee (for example, ~£2 per item).

  • 460–2,000 items: Reduced fee per item.

  • 2,001+ items: Further reduced fee.

• Why This Matters: High-volume claimants (e.g., one doctor administering hundreds of vaccines or B12 injections) can quickly move into the lower fee tier, meaning the practice loses out on the more favorable rate.

• Practical Tip: Distribute claims among multiple prescribers to keep each person below the threshold of 461 items per month. By allocating claims this way—especially during flu season or other high-volume periods - you retain the higher dispensing fee for as many items as possible.

  • No Penalty for Shifting: There’s no penalty or issue with doing this. It’s just good administrative practice to ensure claims reflect the actual prescriber and keep volumes more balanced.

  • Extended Window, No Late Penalties: Because the SFE Directions 2024 allow a six-year submission window, you don’t have to worry about “penalties” if you split large volumes across months. You’re free to organize claims in a way that optimizes your reimbursement as long as each claim is genuine and timely recorded.

(For more on multi-prescriber claim distribution and maximising practice income, see Optimisation Strategies: Making PPA Work for Your Practice.)

High-Volume Vaccine Forms vs. Individual Claims

• High-volume vaccines (e.g., flu, pneumococcal, hepatitis A/B) often go on a special FP34 Appendix form, rather than submitting an individual prescription for each dose.

• All other PPA items typically flow through standard prescription mechanisms in your GP clinical system.

Making sure you code these correctly in EMIS or SystmOne is crucial to being paid accurately. A single oversight—like missing a claim or using the wrong product code—can mean lost income.

(For detailed instructions on setting up your clinical system to generate accurate claims, head to Coding & Claiming Best Practices (EMIS Focus) )

The Bigger Picture

• Item-of-Service Fees: Some vaccines (like flu) also have Item-of-Service payments, separate from PPA reimbursement. Remember to claim both if applicable.

• Practices Keep the Difference: If you purchase an item below the Tariff price, the surplus helps offset practice costs. If you end up paying more, you can lose out—hence the need for smart procurement.

• Large Volume Claims: Periods like flu season or retrospective “catch-up” claiming can spike your monthly PPA totals. With the new knowledge of tiered fees, plan accordingly to avoid falling into the lower-fee bracket.

Conclusion

Understanding the nuts and bolts of reimbursement is key to ensuring your practice recovers the costs of supplying treatments in-house. Keep an eye on Tariff changes, track your discount rates, distribute high-volume claims among multiple prescribers, and claim every item correctly to avoid financial leaks. Meanwhile, the extended six-year submission period offers a safety net for missed or backdated claims—helpful for rectifying oversights without penalty.

Next: Common PPA Items (Vaccines, B12, Contraceptives, etc.)

Looking for More?

• Delve into which items are frequently claimed and how that might shape your practice’s approach in Common PPA Items.

• Curious about how to code them seamlessly in EMIS? See Coding & Claiming Best Practices (EMIS Focus).

• To learn how strategic distribution of claims among prescribers can boost your bottom line, check out Optimisation Strategies.