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Sunday 21 April 2019
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Namaf advises doctors to follow right billing guidelines

Namibian Association of Medical Aid Funds (NAMAF) is concerned with doctors who ignore billing guidelines in order to milk more from medical aids’ coffers while those who are supposed to do the final checks are also napping.
This, the NAMAF CEO Stephen Tjiuoro said this week following recent investigations that revealed how doctors for some time have overcharged medical aids with bloated bills meant to milk the unaware medical aids.
Fraud, wastage and abuse in the healthcare sector is a global problem. The World Economic Forum has estimated that 30 to 50 percent of the 6.5 trillion spent on healthcare worldwide is wasted through misalignment of incentives, interests, strategies and behavior of parties engaged in healthcare.
Because patients rarely see accounts submitted to their medical aid funds on their behalf due to the third-party payment systems, the so-called fee-for-services reimbursement models that are being used in Namibia albeit unintentionally, create incentives for more and sometimes inappropriate quoting. Recently, it has come to the attention of the regulating body that these are global problems associated with inappropriate healthcare expenditures.
The CEO shared evidence of an instance where a doctor overpriced a medical aid for repetitive and questionable services and such amount was paid to the doctor without proper scrutiny by the medical aid.
“What is happening is that doctors put extra services on the bills of the clients. They are aware that the more services they put on, that would translate in more money at the end of the day and since it is how they make money, this trend has been exploited and this is how medical aids are losing money,” said Tjiuoro. (sic)
The extract presented by the CEO after evaluation using the appropriate billing structure now highlights what the medical aid should have paid for and what it should have rejected. However he said without the appropriate knowledge from both ends, no party can be blamed at the moment.
“Seeing that this is a method of making money, you would realise that the doctor would go for everything related to a certain treatment because the more lines he puts on the bill to the medical aid, the more money he gets out.”
At this point I would not say the doctors are doing this deliberately. They have simply been operating in a space where there was no control and no one was asking them questions. We must understand that no one went to school for training on how to use the Namaf quoting structure and many, when caught, simply say they do not know. This is why we have introduced training on the quoting guidelines which would guide the doctor with the relative value of the treatment and the appropriate pricing thereof,” said the CEO.
State PSEMAS and Namaf affiliated medical aid funds have long cried over outrageous amounts they cough up annually for services. An introduction of stipulated guidelines in reference to billing and quoting would thus be a relief to the medical aid funds as far as billing is concerned.
The public medical aid, PSEMAS, caters for the healthcare needs of at least 293 953 beneficiaries and has somehow become victim to the same trend. Reportedly, it stopped paying claims for the second time in as many years, suggesting that PSEMAS is in an even worse situation than those funds affiliated to Namaf.
Namibia is regarded as an anomaly in terms of healthcare spending because it invests huge amounts of money on just a few people.
Although the private sector only provides care to 8% of the population, the money contributed by members affiliated to these medical aids is milked by unregulated doctors.
“This is money belonging to the public and it cannot be used to pay for unnecessary stuff. It has been going on for long and it needs to stop. After the training has been given, we will then exhaust measure to penalise those doctors who continue doing this by either suspending their license or blacklisting them from the medical aids,” said Tjiuoro.
Tjiuoro highlighted that funds affiliated to Namaf are by law subject to a dual regulatory framework; this is from financial or prudential perspectives under the auspices of Namfisa, aimed at ensuring that funds remain solvent and that members are protected against financial mismanagement of their funds.
The Patriot understands that PSEMAS has adopted reactive approaches by trying to recover monies that have already been squandered. Although recovery of such money will typically require long and often expensive legal processes with a small chance of success, the World Economic Forum has recommended that it is important to address the misalignments that prevent healthcare systems from focusing on outcomes and value.
This is not the first time Namaf has been vocal on how medical aids are being milked of millions on an annual basis. The lucrative N$600 million per annum domestic pharmaceutical industry continues to bleed medical aid service providers dry.
Last year Namaf extended an urgent appeal to the health ministry to control medicine prices across the country.




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