The Public Service Employee Medical Aid Scheme (PSEMAS) has recovered a total of N$47 million in fraudulent claims over the years, the Finance ministry has announced.
This is part of a reformation process initiated by the Ministry of Finance and Public Enterprises after a directive from Cabinet called on the Ministry for structural reform of the Scheme as it recorded unsustainable and unexplained expenditure.
“To date, an amount of about N$13 million was recovered in regard to claims related to irregularities such as false representation, dishonest business practices, abuse and over-servicing by healthcare providers,†said Ministry of Finance and Public Enterprises spokesperson Wilson Shikoto.
Shikoto further stated that an additional N$23 million has been recovered from members who are or previously were in arrears with the Scheme. A further N$7 million has been recovered from people who have retired and failed to re-apply for re-admission into the Scheme after retirement.
According to Shikoto, the government enlisted the services of industrial experts to provide actuarial and technical consultancy as part of the reformation process, this includes an examination of the benefits and contribution structure, PSEMAS tariffs and the overall governance and model of the scheme.
“In addition to the overall structural reform, the Ministry has been implementing short- and medium-term administrative reforms to mitigate the identified risks. This includes conducting a total membership re-registration aimed at data cleansing and elimination of possible ghost members. To date, 36 offices, ministries and agencies have completed this process,†Shikoto said.
Shikoto explained that the government has also enhanced the system aimed at automating the membership management thus eliminating and minimising the human interface that could be associated with systemic fraud abuse.
The administrative interventions have also seen the introduction of members’ claim SMS notifications to curb fraudulent claims through identity thefts.
To reform the Scheme, the Ministry appointed auditing firm Deloitte to conduct a compliance audit on the fund’s administrator, Methealth Namibia Administrators.
Shikoto said the audit focused on assessing compliance with PSEMAS rules and benefit structure including management commentary and recommendations.
“In October 2023, the Ministry received the final Compliance Audit Report, which includes management commentary and recommendations,†Shikoto said.
He also pointed out that the report shows that lack of integration between the Ministry and Methealth causes discrepancies in the two data systems. Shikoto however said this would not be enough to conclude that there are “ghost†beneficiaries in the system.
“An investigation will be undertaken to fully understand the source of the data discrepancy and be remediated accordingly,†he said.
Shikoto also said the Ministry has developed an implementation action based on the recommendations provided by the report.
PSEMAS was awarded N$200 million to meet the anticipated deficit in the mid-year budget allocation.
