State recovers N$13m of Psemas money

LAZARUS AMUKESHETHE finance ministry has recovered about N$13 million since June 2018 from healthcare service providers who had submitted incorrect payment claims.

The N$13 million includes claims of N$7 million from a single healthcare practitioner who duped the ministry in fraudulent medical aid claims over an unknown period. The single practitioner has paid the N$7 million back.

Finance minister Calle Schlettwein revealed this as part of his answer to Popular Democratic Movement (PDM) parliamentarian Nico Smit in the National Assembly last week.

Smit had asked for an update on the alleged fraud, abuse and overservicing on the state-owned medical aid fund, the Public Service Employees Medical Aid Scheme (PSEMAS).

Smit had also asked how much the medical aid scheme had lost through fraudulent claims submitted by service providers; whether there were any police investigations and charges emanating from the matter; and what the ministry was doing to stop it.

Schlettwein said about N$13 million was recovered, while N$14 million was withheld since June 2018 because of claim reversals and pending investigations.

The minister could, however, not say how much was lost since the fund’s establishment.

International Monetary Fund (IMF) report, titled ‘Fiscal Risk Statement’ and authored by the ministry and the fund, had attached a figure to fraud, waste and conspiracy last year.

The report had said estimates suggest that dishonesty had cost the fund up to N$900 million per year due to fraud, abuse, waste and collusion, which the minister said was unverified, and he was unaware of the matrices used to arrive at the figure.

Explaining the findings of investigations into alleged fraud, the minister said when it was noticed that PSEMAS expenditure was skyrocketing, the fund’s administrators, Methealth Namibia, conducted a peer review process in April 2017.

According to Schlettwein, the review flagged 82 healthcare service providers and recommended them for further investigations.

The 82 suspect cases led to 29 forensic investigations, currently with only one case solved, while others are still underway. Of the 29 cases, Schlettwein said six irregularities were found in the claims submitted for payment.

He said the guilty healthcare practitioners range from dentists, general practitioners, a pharmacy, medical technology provider, pathology laboratory and a dental therapist, who knowingly used wrong tariff codes to claim higher amounts, and used emergency codes for normal procedures, while some practitioners were unauthorised, and others issued prescriptions for unseen patients.

The Namibian saw the list of forensic investigation findings which shows that some general practitioners claimed payments for treatment rendered to deceased patients, while some pathologists claimed outside their scope of practice. The long list of findings suggests that no verifications of claims were made before payments to service providers were made, and in one case, more than one circumcision claim was submitted for a single patient.

While some practitioners admitted wrongdoing, Schlettwein said only one agreed to pay back the money. A document seen by The Namibian shows that the finance ministry has reported three cases to the police for criminal proceedings, while the Anti-Corruption Commission (ACC) is investigating one case.

A separate case is under arbitration, and the Office of the Government Attorney has taken up two other cases.

Schlettwein further stated that two staff members in his ministry have been arrested and charged for defrauding the state of about N$138 000, and more cases involving employees in the ministry are being uncovered during an audit process which is still underway, with suspects being handed over to the ACC.

Since his appointment as finance minister in 2015, Schlettwein has reportedly blocked various suspected fraudulent deals involving the government. He is the first top official to give details about findings of investigations into alleged fraud and maladministration in the medical aid fund that has about 290 000 beneficiaries since the milking of the fund was first reported around 2010.

He added that his ministry expects to recover a further N$23 million, with engagements and debt handovers underway.

On measures to curb fraud, he said the ministry had de-listed over 17 000 dependants who have reached the age limit, with developments now planned that would allow the dependants who reach the age limit to be automatically de-listed.

Schletwein further said reforms to the medical aid fund that are underway will also look into updating membership data, and conducting audits within the medical aid division of his ministry, especially after some employees from his ministry started resigning when the investigations began.

Psemas reforms have been ongoing for years. Sources within the public service told earlier this year that high-ranking officials responsible for the management of Psemas are incompetent, and continue blocking developments that would bring the needed control over the fund.

The Office of the Prime Minister drafts PSEMAS policies, benefits, procedures and rules, while politically connected Methealth Namibia Administrators manages the processing of claims. The finance ministry is responsible for membership registration and termination, as well as for the payment of claims.

Findings suggest that no verification of the claims processed on behalf of the fund is made, with state expenditure on the fund standing at about 1,4% of GDP and 3,8% of government expenditure.