THE Ministry of Finance is hot on the heels of medical service providers who overcharge, over-dispense or submit fraudulent claims on behalf of civil servants, costing the State millions of dollars.
It has already found four civil servants who have abused the system and are likely to face misconduct charges in terms of the Public Service Act. A study by the Public Service Employees Medical Aid Scheme (PSEMAS) has found that Government has been overpaying for services by up to 30 per cent.”It gave us a serious warning that we are not getting what we are paying for,” said Finance Permanent Secretary Calle Schlettwein in an exclusive interview with The Namibian.”We are not there to challenge their ability to do their job.Our job is to see that the financial side is being done correctly.”A countrywide audit of medical service providers has led to around 40 of them being audited for suspected abuse of the system.Although Schlettwein could not immediately say by how much the system has been defrauded to date, one medical practitioner is believed to have submitted fraudulent claims in excess of N$1,3 million.Government budgets N$500 million a year for medical services to the fund’s 137 728 members and beneficiaries.In December, Finance Minister Saara Kuugongelwa-Amadhila had to approach Parliament for an additional N$65 million because the fund had depleted its budget, mainly as a result of increasing HIV-AIDS treatment.Schlettwein said an overhaul of the system was aimed at reducing costs without affecting the range of benefits.To date PSEMAS has only suspended the payment of services to one medical practitioner at Katima Mulilo, Dr Kinnie Ward, for high claims.While PSEMAS members are still permitted to consult him, they have to pay for the services upfront and then claim from the medical aid.Government has already instituted a civil claim against Ward and the medical board is expected to take any further appropriate action.”The possibility does exist that more practices could be suspended [from the scheme],” warned Schlettwein.Before his death last month, PSEMAS also put on hold payments for its members to dentist Hugo van Staden, who had been practising in the Rundu area.He was found to be submitting fraudulent claims.Van Staden recently committed suicide in South Africa, but Schlettwein said the more than N$1 million he is suspected of having defrauded the system would be claimed against his estate.To date, medical service providers have been found to either over-dispense medication or to dispense medication not relevant to the condition.By the end of the year, the medical aid scheme hopes to put in place limitations on claims.Currently, there is no limit to the number of times PSEMAS members or their beneficiaries may consult a medical practitioner, as is the case with most private medical aid schemes.”We don’t want to take away their benefits or the opportunity to see a doctor, but rather to instil some responsibility in our members,” said Schlettwein on clamping down on frequent and non-urgent visits to doctors.”Financial sustainability is the key.If it’s not affordable anymore, then the whole scheme is at risk,” he said.Another area the scheme plans to manage better is the treatment of chronic diseases.Schlettwein envisages that the system will be running more efficiently by November, when new regulations should be in place.PSEMAS has already instituted a better checking system at service providers by requiring members to fill in forms to verify the services they have received as well as to identify themselves again at the point of service.The Ministry has enlisted the services of private consultants at a cost of N$200 000 a month to refine the system.The process to identify service providers and members abusing the system will continue, Schlettwein said.Members have been found to be submitting claims to PSEMAS for services already paid by a private medical aid fund to which a spouse belongs.PSEMAS members have also been getting away with obtaining medical services for people not listed as beneficiaries of the scheme.A study by the Public Service Employees Medical Aid Scheme (PSEMAS) has found that Government has been overpaying for services by up to 30 per cent.”It gave us a serious warning that we are not getting what we are paying for,” said Finance Permanent Secretary Calle Schlettwein in an exclusive interview with The Namibian.”We are not there to challenge their ability to do their job.Our job is to see that the financial side is being done correctly.”A countrywide audit of medical service providers has led to around 40 of them being audited for suspected abuse of the system.Although Schlettwein could not immediately say by how much the system has been defrauded to date, one medical practitioner is believed to have submitted fraudulent claims in excess of N$1,3 million.Government budgets N$500 million a year for medical services to the fund’s 137 728 members and beneficiaries.In December, Finance Minister Saara Kuugongelwa-Amadhila had to approach Parliament for an additional N$65 million because the fund had depleted its budget, mainly as a result of increasing HIV-AIDS treatment.Schlettwein said an overhaul of the system was aimed at reducing costs without affecting the range of benefits.To date PSEMAS has only suspended the payment of services to one medical practitioner at Katima Mulilo, Dr Kinnie Ward, for high claims.While PSEMAS members are still permitted to consult him, they have to pay for the services upfront and then claim from the medical aid.Government has already instituted a civil claim against Ward and the medical board is expected to take any further appropriate action. “The possibility does exist that more practices could be suspended [from the scheme],” warned Schlettwein.Before his death last month, PSEMAS also put on hold payments for its members to dentist Hugo van Staden, who had been practising in the Rundu area.He was found to be submitting fraudulent claims.Van Staden recently committed suicide in South Africa, but Schlettwein said the more than N$1 million he is suspected of having defrauded the system would be claimed against his estate.To date, medical service providers have been found to either over-dispense medication or to dispense medication not relevant to the condition.By the end of the year, the medical aid scheme hopes to put in place limitations on claims.Currently, there is no limit to the number of times PSEMAS members or their beneficiaries may consult a medical practitioner, as is the case with most private medical aid schemes.”We don’t want to take away their benefits or the opportunity to see a doctor, but rather to instil some responsibility in our members,” said Schlettwein on clamping down on frequent and non-urgent visits to doctors.”Financial sustainability is the key.If it’s not affordable anymore, then the whole scheme is at risk,” he said.Another area the scheme plans to manage better is the treatment of chronic diseases.Schlettwein envisages that the system will be running more efficiently by November, when new regulations should be in place.PSEMAS has already instituted a better checking system at service providers by requiring members to fill in forms to verify the services they have received as well as to identify themselves again at the point of service.The Ministry has enlisted the services of private consultants at a cost of N$200 000 a month to refine the system.The process to identify service providers and members abusing the system will continue, Schlettwein said.Members have been found to be submitting claims to PSEMAS for services already paid by a private medical aid fund to which a spouse belongs.PSEMAS members have also been getting away with obtaining medical services for people not listed as beneficiaries of the scheme.
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