BEWARE MEDICAL AID FRAUD

Medical Aid companies have reported that they are currently losing about seven to 15 percent monthly on fraud payments. Medical Aid funds/Scheme (MAFs) are regulated and supervised by Non Banking Financial Institutions Regulatory Authority(NBFIRA). However NBFIRA states that there are currently no subordinate regulations and rules to license and monitor the MAFs effectively. Available figures from NBFIRA show that currently MAFs only cover about 18 percent of the population of Botswana and as at end of December 2014 they covered 385, 470 lives.

A leading medical aid company Bomaid, says it has come across cases of medical aid fraud over the years in which some members and service providers such as doctors and medical facilities have attempted and even succeeded in defrauding the scheme. Sales and Marketing Manager at BOMAID, Beulah Mapitse said this is done mostly by a small proportion of members and service providers.

“Medical fraud is an expected occurrence in the medical aid industry. “A widely held view is that about seven to 15 percent of scheme expenditure could be a result of fraudulent activities by members or providers,” she said. She said there is a need for robust and integrated information management systems. BOMAID has over time tackled specific cases in line with the peculiarity of each case but the industry collaboration would add more value to solve this problem, she said, adding that this would increase statistical credibility, higher chances of detecting unusual trends as well as outlier billing and claiming patterns by either members or providers.

Pula Medical Aid Fund Principal Officer, Thato Moumakwa recently concurred that most of the challenges they are experiencing are fraud, waste and abuse. “We have discovered that about 26 percent of the claims paid out annually are fraud, waste and abuse claims. We need to put in place some measures that can mitigate this risk,” said Moumakwa.He said they lose about five percent of their monthly payments on fraud claims. Moumakwa said despite the challenging operating environment, they are continually coming up with strategies to take their business forward.

Associated Fund Administrators’ Managing Director, Duncan Thela said the fund is making innovative technical advances to offer speedy claims and payments as well as integrations with various health service suppliers for the benefit of its customers. Since 2014, it has introduced electronic data interchange, which enables the guarantee of payments for services accessed by the customers. Currently 66 percent of claims are electronic.

This has assisted in improving relationships with service providers and customers, said Thela. He said on average more than 25 000 beneficiaries are provided access to private health care services from local facilities and outside the country per quarter. In 2012, NBFIRA engaged KPMG Consultants to conduct research which would recommended to NBFIRA whether to draft a new and specific legal framework which introduces regulations and rules for MAFs or to transform the MAFs to underwrite health insurance as insurers under the regulation and supervision of the Insurance Industry Act.

The study report established the need for a clear and separate regulatory framework that will protect the contributions of members, ensure the sustainability of the industry and most importantly continue to provide health care funding to Batswana. It was recommended that new regulations and rules be promulgated to cater for this.