The Namibian Association of Medical Aid Funds (NAMAF) says it plans to overhaul the country’s medical coding system, aiming to enhance transparency and increase accuracy in healthcare billing practices.
The transition involves moving to the International Classification of Diseases (ICD) 10 system, a precise diagnostic code framework.
According to NAMAF’s Corporate Affairs Specialist Uatavi Mbai, the initiative seeks to address longstanding challenges in the healthcare sector, particularly concerning the lack of specificity in medical billing and the potential for overpricing.
Mbai emphasised the importance of regulating the clinical aspect of healthcare delivery through a robust coding structure.
“We regulate the clinical aspect of things. That’s why we are talking about the coding structure that we want to introduce. We are saying, we are introducing diagnostic code,” Mbai stated.
The diagnostic codes, aligned with the international standards set by the World Health Organisation (WHO), provide detailed information about patients’ conditions and treatments.
By implementing a more precise coding system, healthcare providers will be required to specify the nature of each medical visit and treatment, eliminating ambiguities and arbitrary billing practices.
Mbai highlighted concerns about the current system’s inadequacies, where patients often receive generic diagnoses and treatments without proper examination or consideration of their specific ailments.
“Funds make assumptions based on the medication that you are prescribed… So, we are saying for every visit, we want to know what you’re treating the patient,” Mbai asserted.
However, she added that the transition faces challenges, including system and regulatory issues. Despite introducing the new coding structure two years ago, implementation has been hindered by legal and technological constraints.
“We introduced it about two years ago, but we have system issues. So right now, we didn’t have the system, we had legal issues. Our act is old, so our regulation has loopholes,” Mbai explained.
To address these challenges, NAMAF is working to educate healthcare professionals and stakeholders about the new coding system while providing technical implementation support.
The association aims to achieve a utilisation rate of 70% by closely monitoring adoption rates and offering training programs to ensure compliance.
Effective 1 January 2025, NAMAF plans to enforce stricter guidelines, mandating that all medical claims indicate the diagnosis using the International Classification of Disease (ICD) 10 codes.
This comes after, in November 2023, NAMAF announced that the N$5 billion medical aid funding industry is under financial pressure with utilisation as the root cause.
This move comes as hospitals, medicine, and specialist services collectively account for approximately 31%, 16.7%, and 11.4% of the highest cost drivers for medical aid funds, respectively.
NAMAF Chief Executive Officer Stephen Tjiuoro underscored the pressing need for intervention, stating, “Since the cost of medicines represents the second-largest part of healthcare costs in the privately funded health care industry, NAMAF is in the process of implementing a Namibian NAPPI Product and Price File to assist the industry by establishing a benchmark dispensing fee for medicine in the country.”
The CEO noted that the Namibian medical aid funding industry currently operates under a fee-for-service reimbursement model, which is susceptible to various funding and tariff coding issues.
“These issues include over-servicing, up-coding, unbundling, code farming, inappropriate combinations of codes, inappropriate application of code modifiers, and non-application of code modifiers,” he said.
Analyses conducted by medical aid fund administrators and NAMAF reports indicate the prevalence of clinical coding issues within the Namibian medical aid funding industry.
Tjiuoro emphasised the need for industry-wide cooperation to achieve meaningful utilisation reform.
“The industry-wide stricter application of the NAMAF Billing Rules and Guidelines and international coding conventions must be achieved to address utilisation,” he stated.
