Doctors at war with BoMaid
Recent allegations against one of Botswana's leading health insurers - Botswana Medical Aid Society (BoMaid) - have generated a significant buzz in the health sector.
There are numerous claims of outdated payment policies, reduction in General Practitioners (GP) consultation benefits, and ineffective communication with both service providers and members.
Botswana Guardian investigations have unearthed disturbing trends that could significantly impact the health and wellness landscape in the country.
To begin with, service providers say BoMaid follows a payment policy where reimbursements are made after 30 days - a practice that has been widely criticised as outdated.
Notably, a World Bank report highlights the growing trend of real-time payments around the world.
'In an era where efficiency is key, such delayed payment cycles can strain the finances of service providers, impacting their ability to deliver quality care,' one of the Francistown based service providers said.
BoMaid which recently held its Annual General Meeting is the largest open medical aid fund in Botswana providing products and services to its estimated 42 635 principal Members and 93 926 people across Botswana.
Reports also suggest that BoMaid is consistently falling behind its promised weekly payment schedule. Despite BoMaid's assurances that there are no 'late' or overdue payments, there is evidence of numerous instances of
service providers who complained about payment delays.
'Even though the medical aid society has now illegally resorted to pay us in 30 days, they still fail to pay us all the claims. Remember we signed a contract with them to pay us weekly but they changed the contract without informing us. They owe service providers millions of Pula,' another service provider in Gaborone said.
Concerns also centre around the reduction of benefits for GP consultations. BoMaid defended this by stating their alignment with the 'global average' number of consultations.
However, service providers point out that data from the World Health Organisation (WHO) indicates significant variation in consultation rates across countries, suggesting that applying a 'global average' may not reflect the
unique health trends and needs of Botswana's population.
'Furthermore, the policy regarding additional consultations, which BoMaid has stated would be determined on a case-by-case basis, appears unclear and confusing. No clear criteria for these 'exceptions' have been communicated, leaving members in uncertainty.'
Another major point of contention is BoMaid's announcement of telemedicine services. While the intention behind the move seems noble, implementation appears lacking, it is contended.
Evidence on the ground suggests that many service providers were left without tariff codes and instructions for these services. This raises questions about the effectiveness of the rollout and the insurer's commitment to actual improvements versus mere cosmetic changes.
Moreover, allegations that BoMaid has not fully reimbursed service providers for certain schemes and that doctors are discouraged from initiating preventative care check-ups are concerning.
Data from the National Institute of Health underscores the value of preventative care in reducing long-term healthcare costs, making these allegations particularly troubling.
In their response, BoMaid expresses commitment to holistic wellbeing, proactive care, and best practice processes.
'However, the current situation, backed by empirical evidence, tells a different story. Despite new hires and new health plans, the underlying issues highlighted above persist, casting doubt on the efficacy of their actions.
“It is imperative that Bomaid addresses these concerns sincerely and urgently. With increasing public scrutiny, the organisation's credibility is at stake.
“The health sector is not just about delivering services; it is about trust, care, and a proactive approach towards the health and happiness of the community,' another practitioner said.
While Bomaid argues that it is striving to fight fraud and the abuse of medical aid benefits for its members, it has however been argued that paradoxically, they inadvertently contribute to the exacerbation of medical aid fraud.
Their practice of delayed payments is said to put undue pressure on the cash flows of service providers. This financial strain often drives these providers to inflate costs and even bill for services that were not rendered,
further increasing the cost of healthcare for members, one General Practitioner observed.
Bomaid Chief Executive Officer (CEO), Moraki Mokgosana said they are committed to proactively ensuring better holistic wellbeing outcomes – health, happiness and wellbeing beyond only the clinical or medical.
Doing this, he said, means ensuring “We have the best people in the right roles - a number of strategic new hires such as clinicians and a Chief Information Technology Officer, among others, the right infrastructure - the newly investment in Thobo Fund Administration System, which is an industry benchmark for excellence and the right solutions - a strategic overhaul of our health plans, now with 16 new health plans designed for more agility, inclusion and proactive care for holistic wellbeing. He told Botswana Guardian this week that supporting this is best practice in process, including partner validations, claim vetting, KYC and data processing.
According to Mokgosana, this is what informs payment and processing timelines, 'and as we leverage data and technology to enhance this whilst not compromising standard of excellence, we will welcome more efficiencies”.
After all, he said that as a non-profit society, it is in their best interests to ensure that all in our ecosystem of partners are happy, and our relationships with them is healthy.
“There are no 'late' or overdue payments of note. The revised beneficiary visits have caused some confusion, however as we continue to engage with Members and other stakeholders, people are genuinely starting to see that this does not come from a place of cost containment or even tight management.
“In reality, we are working to help ensure our Members receive the most relevant and best care when in need of medical support.”
The CEO indicated that beneficiary visits apply specific to respective health plans, and were informed by benchmarking with other industry trends, locally and globally, as well as global research.
“That being said, we are absolutely clear that exceptional cases can and will exist. If, for example, a parent has a child with chronic asthma, it is only logical they will need multiple specialist visits.
“When we know this, we tailor our support accordingly. And beyond this reactive approach, we take on a more proactive drive to encourage all Batswana to manage the risk of non-communicable diseases to active lifestyle management, exercise, diet and awareness of one’s health status – our Abby health screening portals make this even easier to do, with an assessment in less than three (3) minutes,” Mokgosana responded.
He pointed out that they are a learning organisation, and where they may meet some frustration or negative feedback, they will continue to listen, internalise and leverage this to do better.
He said this is why all Member and stakeholder feedback is important to them. In addition, their focus is and will always be on working to be a true companion in health, happiness and wellbeing.
He said they have a sound strategy towards achieving this, and yet “we also adapt and grow as we proceed, engaging with our service providers, partners and Members” for the collective good of communities. Above all else, it is about ensuring health and happiness for Batswana, he said.