With the cost of medical services continuing to sky rocket amid allegations of over servicing and fraudulent claims by medical practitioners, the Windhoek Observer (WO) engaged the Chief Executive Officer of the Namibian Association of Medical Aid Funds (NAMAF) Stephen Tjiuoro (ST),
a juristic body, established in terms of the Medical Aid Funds Act, 1995 (Act 23 of 1995) to control, promote, encourage and co-ordinate the establishment, development and functioning of Medical Aid Funds in Namibia to shed light on some of the allegations and developments in the sector.
WO) As NAMAF, have you carried out a study into the issues of claims by medical service providers such as doctors and laboratories, following revelations by government that there seemed to be incidents of irregular claims? And if you have, what were your findings?
ST) The reliable identification of untoward relationships between different service providers are difficult to establish beyond doubt.
NAMAF is in the process of building a comprehensive database through which it will become possible to test these types of allegations. More importantly the intention is to build Business Intelligence tools through which adverse trends will become identifiable proactively.
WO) What is your comment on concerns that despite the country’s inflation being single digit, the health inflation is always double digit, resulting in members and public paying more in medical aid and medical services? Is this practice justified?
ST) Healthcare or medical inflation locally and internationally is driven by many factors. Fundamentally, cost is a function of price and volume and what we are seeing is that the main driver of healthcare costs, or inflation, is the volume or utilisation of services. In turn utilisation is driven by several factors such as:
- Ageing population;
- Increasing burden of disease;
- Greater accessibility to healthcare services;
- Patients demanding more care because they have better access to information and are becoming more educated.
To the extent that higher utilisation of healthcare services cannot be justified clinically and becomes tantamount to over-utilisation or potential wastage, there is cause for concern. Projects are underway to understand this notion better.
WO) As NAMAF, do you think the public is being charged fairly for services by medical service providers?
ST) Fairness is a relative concept and the real question to be asked is whether the public is getting value for the money that they are spending on healthcare. That value can be defined as the quality of care received relative to the cost of that care. In turn, quality is determined by access to care and the clinical outcomes achieved as a result of the care provided.
Therefore, the question is what outcomes are being achieved in return for the money spent. This is a clinical question that is notoriously difficult to answer. In Namibia the difficulty is compounded by the fact that health care service providers are not obliged to provide diagnoses when they submit their accounts. This makes the clinical evaluation of outcomes very difficult, but, again, this is on the agenda and we are working towards implementation of suitable solutions which is the rolling out of ICD coding structure at national level.
WO) Is it fair to say that the Namibian public has been overpaying in some instances for medical services over the years because of cases of over servicing and fraudulent billing?
ST) It would not be fair to make such a statement on an unqualified basis. As indicated earlier, the cost of care should be evaluated in the context of quality of care received and outcomes achieved. We are not able to express an opinion on these two metrics, noting that the measurement of quality and clinical outcomes are topics of international debate. They are very difficult and complicated to measure accurately, and optimal solutions are yet to be found, even in developed countries.
Therefore, the question whether the Namibian public have been overpaying is moot and further work needs to be done on understanding the quality of care that is being provided relative to the cost of the care.
WO) Amid concerns that the public is being overcharged for medical services. What remedies does the public have in such cases?
ST) Patients that feel that they have been over-charged have several potential remedies, noting that overcharging could occur as a result of tariffs, or fees were too high and/or incorrect coding that was applied:
- The first port of call should be to have a conversation with their medical aid fund or the administrator of that medical aid fund. The purpose would be to obtain confirmation whether overcharging had taken place or not.
- If incorrect use of codes is suspected and the medical aid fund’s administrator is unable to assist, patients are welcome to contact NAMAF directly.
- Healthcare practitioners are obliged by law to discuss the cost of services with their patients prior to rendering the services. If patients feel that this did not happen and/or the fees charged were too high, they should approach the Health Professions Council of Namibia (HPCNA) for assistance.
WO) What measures is NAMAF taking to ensure that transparency exist and ethical standards are followed by medical service providers when they make claims?
ST) It is important to note that the ethical behaviour of healthcare practitioners falls under the jurisdiction of the Health Professions Council of Namibia (HPCNA). The ethical conduct is guided by the Health Professions Act and its Regulations as well as ethical rules that are published by the HPCNA. Healthcare professionals are bound by the ethical rules as part of their continued registration by the HPCNA.
One of the purposes of the coding structures and Benchmark Tariffs that NAMAF publishes from time to time is to ensure consistency and transparency in the compilation of accounts for healthcare services provided and the adjudication or processing of those claims. This means that similar procedures should give rise to similar accounts regardless of the provider rendering the services, assuming that all other things are equal.
WO) Do you think medical fund administrators are doing enough to curtail cases of fraudulent claims and do they have the human resources capacity to evaluate all claims made, and of what assistance can NAMAF give to them to avoid such cases?
ST) The administration of medical aid funds is complex due to the high numbers of claims, high numbers of line items per claims and the many permutations that can occur around similar clinical events. This means that clinical situations and the accounts emanating from the situations are often open to interpretation, requiring skilled and scarce resources. So, the answer to the question is two-fold:
- It will never be possible to do enough to curtail fraud fully, because one will always have to try and stay a step ahead of the perpetrators which is easier said than done.
- Detailed assessment of healthcare accounts requires very special skills and a lot of experience and we do have a lack of capacity in this respect.
NAMAF is currently offering comprehensive training and education programs to all stakeholders in the industry to enhance the knowledge and skills in the industry and build capacity.
WO) If medical service providers such as doctors are found to have been over servicing and making fraudulent claims, can they be prosecuted and do you have any cases that you have forwarded for prosecution?
ST) It is important to differentiate between over-servicing and fraud. Fraud is a criminal offence that requires proper criminal procedures to be followed and intent will have to be proven.
Over-servicing can have various formats:
- The most common format is unintentional over-servicing which happens as a result of the environment in which we are operating and where we have:
o A fee for service system that incentivises people to put more line items on their accounts as a natural reaction;
o A third-party payer system with direct submission of claims to medical aid funds which leads to the consumers of healthcare not seeing their own accounts;
o An insurance model where someone else pays the accounts leading to cost and price insensitivity on the part of the consumers and the providers of healthcare.
- Instances of deliberate over-servicing do occur when:
o Providers offer and provide services that are not necessary;
o Providers stand to benefit in other ways from the services that they are offering, such as shareholding in for example hospitals;
o Deliberate use of inappropriate codes and inflating accounts in the process.
Over-servicing is unethical in terms of the ethical rules published by the HPCNA and complaints should be lodged at the HPCNA.
NAMAF is not a directly affected party when it comes to over-servicing and fraud, meaning that it cannot be or assume the role of the complainant. However, NAMAF does play an active role in the identification of misdemeanours and guides affected parties with respect to appropriate actions that can and/or should be taken.
WO) Lastly do you think a full-scale investigation into the costing of medical services including billing practices by doctors should be investigated?
ST) One should be careful not to commission an investigation for the sake of doing an investigation. It will be necessary to predetermine what it is that one is looking for and what the nature of the problem is that one will be seeking to address.
As indicated before, we know that increasing utilisation of healthcare services is one of, if not the, main drivers of increasing healthcare costs and we need to understand what it is driving these increases in utilisation. To this end, NAMAF has already commissioned some research work and will be arranging an industry-wide workshop or symposium during the latter part of the year to present and debate some of the results of the analyses being performed.