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Medical doctors under investigation for fraud

13 October 2017 Author  
The Ministry of Finance has roped in the services of the Anti-Corruption Commission (ACC) to investigate 35 medical doctors over claims that they defrauded the Public Service Employees Medical Aid Scheme (PSEMAS) by overcharging for services.
This comes as the Ministry of Finance has announced a reduced number of PSEMAS medical aid service providers whose contracts were recently renewed.
The Ministry of Finance cancelled all contracts between the ministry, PSEMAS and all healthcare professionals effective 30 June 2017 as it undertook a process of reviewing each participating medical service provider’s contract. 
This audit was necessary after evidence of an ineffective system to substantiate claims and an inadequate administration process to monitor registered healthcare providers caused the leakage of hundreds of millions of dollars as dubious claims were paid out over the years.  The outflow of questionable claims sapped the service provider’s resources.
PSEMAS’ depleted finances caused delays in payments to its service provider which in turn resulted in a financial domino effect as several medical service providers faced severe operational challenges, forcing some of them to close shop as they were unable to pay their operational costs due to unpaid PSEMAS claims. A committee to review all medical practitioners registered with PSEMAS comprising of members from differ­ent health institutions was then established to audit the claims.
According to previous reports, medical service providers claimed around N$125 million in two weeks in December last year, a new record high from an average of N$55 million monthly in the history of the medical aid scheme.
Speaking about the renewal of the contracts recently, Finance Minister, Calle Schlettwein, said that depending on the severity of the fraud, some of the service providers’ claims will not be paid and other legal action may be pursued.
He said service providers whose transgressions do not meet a ‘serious’ threshold would be paid 64 percent of their claims, while those with very serious cases will not be given contracts and other action will be considered.
ACC Director General, Paulus Noah, said this week that his institution was busy with investigations which he foresees taking a significant amount of time because of the detailed investigative process involved.
He said the ACC was interviewing every patient and healthcare provider in the 35 cases and that this is very time consuming.
“This is not an easy process; we have to be very thorough so it will take a bit longer to finish investigations. We are having problems with patients who are claiming to have been treated as some of them were not even aware that they were being tricked, while some are refusing to speak to us completely,” Noah said.
Noa could, however, not provide the names of the different practitioners under investigation and referred this newspaper to the finance ministry, but both the minister and Permanent Secretary, Erica Shafudah, were not in office.
Under the new contracts, the ministry says that they have closed loopholes including that of multiple practices operating under one registration code.
Government paid out N$3.3 billion for healthcare claims by civil servants between 2012 and 2016.
During that period PSEMAS paid out N$1.5 billion to general practitioners, hospitals (N$1.3 billion) while N$495 million went to specialists.
There are 293,953 beneficiaries eligible to utilise PSEMAS. This is nearly 14% of the Namibian population covered under one insurance scheme.
The total increase in benefits paid to general practitioners rose from N$282 million in 2012 to N$319 million in 2016 while that of hospitals increased by over 60 percent from N$129 million in 2012 to N$363 million in 2016.
As for specialists, benefits paid to them ballooned from N$58 million in 2012 to N$138 million in 2016.
Statistics from the Health Professions Councils of Namibia indicate that there are 1,618 medical practitioners and specialists on the national register. This includes Namibians and foreign nationals.

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