Forensic Unit to Tackle Medical Aid Abuse

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By Surihe Gaomas WINDHOEK In order to curb and eliminate corrupt practices of fraud and dishonesty in the medical industry, the Namibian Association of Medical Aid Funds (Namaf) plans to set up a Forensic Management Unit by January next year. By having a fully-fledged forensic management of experts in place with help from South Africa, the envisaged unit plans to detect and prevent fraud, overcharging and incidents of dishonest practices in the medical industry. Speaking to New Era recently, the Chief Executive Officer of Namaf, Andre September, said the objective was not to look at specific stakeholders involved in defrauding, but to take a more general approach. “It’s going to be across-the-board defrauding and not just targeting doctors,” said September, adding that steps are under way to look at modalities as to how this unit will function once it’s implemented early next year. In April last year, the government launched a major investigation into medical aid fraud, specifically in the Public Service Medical Aid Scheme (Psemas) that faced a number of challenges and had fallen prey to corrupt practices from service providers and members. Voicing this concern was Permanent Secretary of the Ministry of Finance, Calle Schlettwein, who said doctors found guilty of overcharging would be exposed through peer reviews done by the health professionals’ governing council. While there is abuse by doctors who allegedly overcharge for services rendered to patients, some patients also abuse the scheme by submitting excessive claims for medical expenses of relatives not listed as dependants, for instance. Around 122 000 people benefit from the government’s medical aid scheme, which costs the state around N$38,6 million a month. Government employees contribute little more than N$7-million a month to the fund. However, the finance ministry has put in place measures to save costs and curb the abuse. One such measure is to carry out a forensic audit whenever fraud or abuse is suspected. “Loopholes in the rules of Psemas that render the scheme vulnerable to exploitation by members and service providers will also be closed,” Schlettwein is quoted as saying in a local daily last year. It turns out that fraud and abuse is a common corruption practice that the medical industry’s stakeholders would like to root out both in the public and private medical sectors. It is against this background that Namaf saw the need to address this problem. “These are the kind of things we want to stop because people do take chances and it’s a growing problem,” added September. In partnership with the Board of Healthcare Funders (BHF) of Southern Africa based in South Africa, Namaf has been consulting its colleagues on how best to come up with a tailor-made forensic management unit that would detect and eliminate fraud and dishonesty within the health sector of the country. Currently, South Africa has a similar unit that has been working effectively in carrying out such duties through a collective approach to prevent fraud and abuse. Outlining this at the recent annual Namaf Conference that was held in Windhoek, expert Heidi Kruger said such fraud happens because people lack understanding of how the medical scheme works. “People hate paying for them (medical schemes) and will take every benefit out of them,” said Kruger. Perceptions are that medical aid schemes are seen as “cash cows” and corruption comes in when some medical professionals abuse the system by overcharging the patient, or the patient claims for services not even provided in the first place. President of the Medical Association of Namibia, Dr Hagen FÃÆ’Æ‘Æ‘ÃÆ”šÃ‚¶rtsch, said in overcharging by doctors a lot of the expenses are pushed onto the patient. A South African black economic empowerment company Zungu Investment Company (ZICO Forensics (Pty) Ltd) has been conducting the investigations in that country. Herman Havenga of ZICO said that it should not be seen as a witch-hunt, but a focus on sophisticated white-collar crime. “It’s no shotgun approach,” said Havenga. Techniques of investigation are analysis, data interrogation by looking at for instance the high claims patterns, dependants and gathering of evidence, which ultimately leads to either civil or criminal proceedings at the end of the day.