Will Forensic Management Unit Stop Fraud?

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By Wezi Tjaronda WINDHOEK In the wake of fraudulent practices and inappropriate behaviour in the medical aid industry, plans are afoot by the Namibian Association of Medical Aid Funds (Namaf) to set up a forensic management unit in order to put a stop to such practices. The association, which represents medical aid funds, is engaged in talks with the Medical Association of Namibia, which is a grouping of doctors, urologists, specialists and dentists, among others, to support the initiative. Over a couple of years back, more and more funds are investigating cases of fraud perpetrated against them, which has strengthened belief that such malpractices are perpetrated across all the funds. AndrÃÆ’Æ‘Æ‘ÃÆ”šÃ‚© September, Namaf Chief Executive Officer, told New Era yesterday the funds decided last year to tackle the problem, hence plans to establish the unit. Although suspicion is that a good percentage of all claims are either fraud or over-usage, September said this could only be certified once investigations are done. There are fears that, if left to continue, these practices could escalate the health care costs, which are already on the high side in Namibia. In this regard, Namaf is conducting investigations to establish the full scope, after which the association will know the incidences of fraud, the kind of fraud, and by whom the fraud is committed. “We know and see the complaints coming in, but an analysis will give us a much better picture,” he said. If all goes accordingly, the unit may be operational after Namaf’s Annual General Meeting scheduled for March 14. The Managing Director of Medscheme, Tiaan Serfontein, said yesterday that his personal opinion was that between 15 and 20 percent of all claims could be connected to fraud or over-usage. In its newsletter, the fund recently warned its members against being involved in fraudulent practices. Serfontein said a number of cases are being investigated, after which the culprits will be prosecuted. He could not disclose the number because he said the investigations were ongoing. September said the fraudulent claims could involve all in the industry, namely: service-providers, members and administrators. While service-providers could submit false claims, change dates of consultation, resubmit claims, over-service their clients, provide services to non-members and alter scripts, the members could be involved in dual membership, which is against the law and member substitution. Over-servicing refers to a patient who has to return to the doctor now and again even when in the healing process, while script alteration is when a doctor prescribes a generic but the service-provider alters the script to portray as if the patient was supposed to get an ethical drug, and claims for it. September said administrators could divert funds, collude with service-providers and manipulate claims. He said fraud was a broad problem, and the association was trying to be systematic because funds are individually investigating cases and taking action. He added that members of the funds would have to continually be sensitized on what they are doing to make them understand that fraudulent activities add to the costs of health-care.