Government is set to sign new contracts that oblige all individual healthcare facilities and/or practices to obtain a practice code number, if such provider wishes to claim directly from the Public Service Employees Medical Aid Scheme (PSEMAS), the Windhoek Observer can reveal.
This development would address some of the various challenges that have dogged the medical fraternity lately following the unearthing of irregular claims that have milked dry PSEMAS which has been struggling to pay outstanding invoices.
According to sources close to the Windhoek Observer, who preferred anonymity, the cancellation of current contracts and subsequent signing of new ones at the beginning of next month was the only hope of addressing fraudulent claims.
The sources said since last year, Government had been overwhelmed with claims from practitioners running multiple practices in different suburbs, towns or regions around the country.
“The Government has noticed that these practitioners had several practices and deployed other practitioners to work for them and share the remittances on a monthly basis, without them physically visiting their said practices.
“So this move to have new contracts will also be coupled with other new statutes such as that every single practice have its own practice code number unlike now where a single code can be used at multiple practices.
“Running many practices makes it hard not only for medical aids to monitor the practice’s compliance with the rules, but it affects even the ability of the Ministry of Health and Social Services (MoHSS) to ensure that such a practice complies with minimum requirements, as each practice should be inspected prior to commencing services.
“Traditionally, practitioners who have more than one practice need to only register for additional practice numbers based upon the locations of their practices.
“Nevertheless, it is unlawful to hire other doctors to run these other practices only to have them claim under your own Namibian Association of Medical Aid Funds (NAMAF) number.
“Previously, provisions have been made to allow locums to use practice numbers of practice owners for a period of up to six months, but thereafter the locum doctor needs to apply for their own NAMAF number,” the sources said.
The new development would also affect claims made through the Motor Vehicle Accident Fund (MVA Fund) although PSEMAS and the MVA Fund are not part of NAMAF.
The Pharmaceutical Society of Namibia (PAN) President, Benjamin Khumalo, said he supports Government’s efforts to streamline things and make sure PSEMAS was sustainable to achieve its objectives.
Khumalo said it has always been a requirement that each practice has its own practice number to ensure transparency and compliance with the rules. He expressed confidence that the proposed move was not to punish anyone, but to make sure things were done properly.
“There have unfortunately been reports of practitioners opening multiple practices using their own names and placing people not properly trained to run the practices for them while they are working at another practice. The whole idea is to root this out.
“So, if they share a practice number you will never know which actual practice to go to in cases of inspections, or if there is a complaint by a member of the public, for example.
“This also makes it easy for practitioners to get away with fraudulent activities and we cannot have Dr X seeing two patients at the same time in two different towns.
“It is very important and also a patient’s right to know the healthcare practitioner providing services to them, so having Dr X in two different places at the same time means one of the two is definitely not Dr X.” The Medical Association of Namibia (MAN) Chief Executive, Dr Armid Azadeh, said the benefits of the said development should be clear to see, as there would be less room for abuse of medical aid funds, while collecting an evidence base to evaluate doctors, and how many patients they are seeing and where.
Dr Azadeh said other medical aid funds administered by NAMAF do not appear to have the same scale of abuse, as they frequently flag practice numbers that are being used in multiple locations; more-so when their claiming patterns indicate that there is likely to be multiple doctors using that same number.
“This idea or initiative is nothing new. NAMAF as it stands now has rules in place when issuing practice numbers to individual doctors based upon a single practice location.
“When doctors use identical practice numbers for multiple locations this is incorrect from the part of the doctor. The issuing of a NAMAF number to a practitioner is based upon certain criteria being met, such as HPCNA registration, and MoHSS certification of location.
“We have addressed this abuse with PSEMAS on numerous occasions. MAN does not apportion blame to Methealth and PSEMAS specifically, but somewhere along this arrangement it seems the rules are ignored or bypassed,” Dr Azadeh said.
NAMAF Chief Executive Officer, Stephen Tjiuoro, remained adamant that it has always been the norm as prescribed by Section 5 of the Regulations to the Medical Aid Funds Act, Act 23 of 1995.
Tjiuoro said this Act states that each healthcare facility and/or practice must obtain a practice code number if such provider wishes to claim directly from all the private medical aid funds and by extension from PSEMAS and the MVA Fund.
“The requirement from NAMAF, as it currently stands, is that each practitioner who owns multiple practices should ensure that each facility/practice has a practice code number and that all the practitioners who work at those practices/facilities are properly registered with the relevant entities.
“Nothing is actually going to change. Do not confuse the PSEMAS decision to terminate all the contracts with their contracted healthcare providers with the operations of NAMAF and the private medical aid funds who statutorily constitute NAMAF,” said Tjiuoro.