… pending PSEMAS probe
By Confidente Reporter
HEALTH service providers will not be paid through the Public Service Employee Medical Aid Scheme (PSEMAS) but are expected to render health services until the Ministry of Finance concludes investigations into possible fraudulent N$125 million claims submitted in less than two weeks in December, Confidente has learnt.
Confidente last month broke the story that medical service providers claimed around N$125 million, a new record high from an average N$55 million monthly in the history of the medical aid scheme. This has prompted the Ministry of Finance to not only tighten its purse but also to establish whether the claims are legitimate or if service providers inflated their rates to fleece Government.
Confidente recently established that the Finance Ministry put in place a review committee comprising of members from different health institutions to audit the claims.
Finance Minister, Calle Schlettwein Monday confirmed the committee’s establishment that will amongst others validate as well as audit all claims submitted to PSEMAS over a certain period of time. “That is correct. We meet the committee again when the first report becomes available,” he said.
Documents in Confidente’s possession reveals that the committee will also gauge PSEMAS claim patterns so as to identify health service providers with suspicious high claims.
“The main function of the committee will be to audit all the claims submitted to PSEMAS, within a certain period of time and will have the mandate of the Minister of Finance to fulfill this function. This will be done in cooperation with the administrator of PSEMAS.
“…The reason for this auditing process is to identify if there are practices with suspiciously high claims/tariffs in comparison to the others. If a practice is red-flagged because of alarming high claims/tariffs that practice will be further investigated and will not be paid by PSEMAS until investigation is completed. All practices can expect no payment from PSEMAS until this audit is completed,” reads the document in part.
However, a resolution between the ministry and health institutions following special meetings suggests that a portion of the outstanding claims will be paid in the next fiscal year.
“…Health service providers should indicate through their respective governance structures, the minimum percentage amount of outstanding claims that is required to take them through up to the end of March 2017, with the understanding that the balance will be paid in the next financial year and that PSEMAS patients will continue to access health services as usual.”
Meanwhile, service providers who preferred anonymity told this publication that as a result of the audit and delay in payments, PSEMAS patients are either turned away or asked to pay upfront for medical services.
“The last payment from PSEMAS was processed in January, lately it’s quiet. PSEMAS patients are thus either turned away or asked to pay upfront for medical services but this differs from practice to practice. Some medical service providers continue to render their services, submit claims which means Government owes them. Hopefully we will be paid after the tabling of the new financial year.”
On average the Finance Ministry releases about N$55 million monthly to PSEMAS and never in the history of the medical aid scheme has there been monthly claims that surpassed the amount.
Schlettwein last month said, “There are a number of issues we are looking at. It’s a complex issue. There is serious price escalation being looked at on whether it’s legitimate or its possible medical aid fraud.”
High ranking sources in the know who also spoke on condition of anonymity at the time said, “With each payment run PSEMAS gets about N$55 million to pay everyone. How¬ever for the first time in 22 years, the claims in December, the quietest period, went up to N$125 million. This was obviously way above the N$55 million they are used to. Some providers we are told claimed as much as N$1.2 million during this quiet period, more than what they do during busy times like June and July. Obviously that’s a serious anomaly. As a result some of the providers’ staff is undergoing forensic audits because quite frankly, fraud is suspected sadly.”
There were also reports that PSEMAS was bankrupt but sources said the assertion is not factually correct. “In short there is money and money will keep being released but because claims in just 11 days of the quietest period of the year trebled from what they’re used to paying, PSEMAS managers had to now wait for senior staff to come back from the December holiday to ask for more money. There won’t be money withheld for payment to members.
Money will be allocated as it gets released as usual. They were first looking at updating everyone and making sure everyone is covered up to the last day of December.
“So going forward, we agree to work closely with PSEMAS to ensure that there are no more delays. In the interim they asked that we help PSEMAS clients, as they are working at resolving the situation. There’s no money permanently kept in the PSEMAS kitty. Money gets released monthly and they simply allocate it. What was also mentioned was: the minister had a meeting with PSEMAS officials this past week and they’re working on different strategies and models to ensure they bring everyone up to date with payments.
They unfortunately can’t say when but we did our best to indicate how bleak the situation is, and what effects it would have.
We won’t pay suppliers, they won’t pay manufactures, business will collapse, and we will have to retrench people,” the sources revealed.
While the Finance Ministry only tightened its purse recently, health professionals questioned why it took Government so long to act adding the relationship between administrators and service providers should be investigated.
“Why were people not worried back then when such claims were submitted? How is it that this was not picked up a long time ago? Why is it that claim patterns were not investigated when administrators saw a difference in claims submitted? When the claims increased, the administrators should have asked themselves whether more people got sick suddenly, whether the population tripled overnight hence an increase in people seeking medical services. But such red flags were ignored and we find ourselves in this situation.
“There are cases where only claims of a handful service providers would be processed while other were left out. This is a clear case of favouritism and just show how administrators are the root cause of this problem. They were not honest in their execution of duties.”
The health providers called for stricter safeguards against fraudulent claims by service providers as well as preventing potential fraudulent claims.
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