Unsuspecting patients and medical aid funds have been fleeced millions of dollars through over charging and over servicing by Namibian doctors, it has emerged.
Information gathered by the Windhoek Observer revealed that several doctors have been raking in millions of dollars annually through fraudulent claims,
while desperate unsuspecting patients who are not covered by medical aid funds, have had to dig deep into their pockets to meet the costs of their medical expenses.
The revelation comes as government is battling to recover millions fleeced from the Public Service Employees Medical Aid Scheme (PSEMAS) by medical service providers through massive irregular claims.
The government medical aid scheme is said to be struggling to meet its obligations as a result of the fraudulent claims, with reports estimating the losses at N$900 million per annum.
An investigation by the Windhoek Observer revealed that doctors in some cases overcharge patience by performing unnecessary procedures or through double claims for a procedure which should have been carried out once.
In one particular incident, a Windhoek based medical doctor who is known to the Windhoek Observer, claimed in excess of N$19 million when he was only entitled to N$7 million.
Leakages are also being caused by doctors making use of inappropriate medical aid claim codes.
The situation is said to have been worsened by patients’ inability to question procedure quotes by doctors due to lack of knowledge and capacity on the side of medical aid administrators.
In some cases, over servicing by doctors is said to be the main reason why benefits of some members deplete so fast.
Medical laboratories, working in cahoots with some doctors, have also benefited from malpractices as doctors request unnecessary tests for patients in order to claim a commission from laboratories.
The unethical practice by doctors, according to information availed to the Windhoek Observer, is suspected to be reason behind the increased wealth of many of the country’s doctors, who in some cases claim amounts as high as N$20 million per annum from private medical aid funds.
The medical sector has also been accused of pushing premium contributions by increasing service costs with double-digit figures annually, despite the country’s inflation hovering around 5 percent on average.
“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.
“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,” Namibian Association of Medical Aid Funds (NAMAF) Chief Executive Officer, Stephen Tjiuoro said
He said NAMAF, which is 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, was in the process of building a comprehensive database through which it will become possible to test allegations being made against medical service providers.
“In Namibia, the difficulty is compounded by the fact that healthcare 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.”
Quizzed on measures NAMAF will take in cases where doctors and medical services providers are found to have fraudulently claimed or over serviced patients, Tjiuoro said, “It is important to note that the ethical behavior of healthcare practitioners falls under the jurisdiction of the Health Professions Council of Namibia (HPCNA)”.
He said the ethical conduct is guided by the Health Professions Act and its Regulations as well as ethical rules that are published by the HPCNA.
He said 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. 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.”
Tjiuoro said detailed assessment of healthcare accounts requires very special skills and a lot of experience.
“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,” he said.
When contacted for comment, the HPCNA said it needed more time to respond to queries.
“I hereby acknowledge receipt of your email. We are unable to assist you due to your deadline,” said a staff member at HPCNA.
Efforts to contact the Medical Association of Namibia (MAN) Chief Executive, Dr Armid Azadeh, regarding allegations against doctors were fruitless, as calls made to the organisation’s office remained unanswered.
According to media reports, a forensic investigation commissioned by government is underway to determine the extent of fraudulent claims against PSEMAS with N$23 million envisaged to be recovered.
About N$13 million of that amount is said to have been recovered already.
In 2017, medical aid contributions stood at N$3,7 billion, with N$309 million paid to medical fund administrators for their services.