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Botswana: Doctor-Hopping Pushes Up Medical Insurance Claims
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Mmegi/The Reporter (Gaborone)
2 April 2008
Posted to the web 2 April 2008
Thato Chwaane
Doctor-hopping and possible fraud have been identified as factors behind the escalation in claims since 2005, the Deputy Managing Director of Associated Fund Administrators (AFA), Rose Tatedi, told a Pula breakfast seminar last Friday.
Tatedi said because of this escalation, they have had to use reserve funds to pay for some of the claims. This has been a problem because contribution income has not been increasing at the same rate as claim costs. Tatedi said that to manage doctor-hopping, they have introduced a referral system under which a member of a medical aid is expected to register a primary doctor, who is a general practitioner (GP), with the Fund who is responsible for any referrals to medical specialists.
A little over 2 000 members have completed the necessary forms and returned them. The deadline for the submission of completed forms is June 30, 2008. Tatedi said the benefits of the system include increased quality of care, reduced costs of care, improved relations and increased confidentiality. Explaining further, she said a member could be treated on an emergency basis if they happen to be away from their usual residence or far away from the primary doctor; members are free to change doctors if they should so wish.
Other issues pushing costs up are members asking a doctor to attend to someone who is not covered. This and other challenges of service providers' behaviour have been referred to the Botswana Health Professionals Council and the Ministry of Health.
The Pula Medical Aid Fund was established in July 1991 and currently has 13, 461 principal members and 17, 749 beneficiaries. Tatedi said they refund members or pay for services on a monthly basis and that they have maintained healthy levels of reserves in the past.
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The Managing Director of AFA, Kabelo Ebineng, explained to concerned members at the seminar that it was decided at an annual general meeting that parents of principal members should not be covered by the scheme after consultations. Responding to a participant regarding infertility, Ebineng said it was an expensive and emotional issue; because Government is developing a bill on tissues and he said the hope was that the issue of infertility would be solved in a couple of years. The seminar was meant to facilitate interaction between member employer groups representing beneficiaries and the management of the medical fund.
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