Bloodwork now billed as a consultation
Any deviation from a rule requires Namfisa's approval and cannot be unilaterally implemented by medical funds.
From 1 January next year, drawing blood is part of a consultation and can no longer be invoiced separately.This comes after the Namibian Association for Medical Aid Funds (Namaf) decided according to its rules and regulations for 2025, that the billing code 0210 is no longer allowed with a consultation.
Several administrators of medical funds in Namibia have, with the permission of Namaf, already placed restrictions on claims that use specific codes. These restrictions can already be applied with the provision of the relevant fund's rules.
However, the restrictions on payments of valid claims that meet Namaf's standard rates were done without any prior notice or willingness to address legitimate concerns by affected parties, says the Namibian Private Practitioners Forum (NPPF).
NPPF's CEO, Dr. Jürgen Hoffmann, says that drawing blood often involves patients who are very young, sick or scared and have "difficult" veins.
“Required protocol for pathology, sample preparation and transport requirements add to the complexity. This clearly distinguishes the code (0210) from a simple consultation (0101)," he explained.
Hoffmann says 0210 reflects a "full, legally required protocol, not just the insertion of a needle".
According to the law for medical funds, funds rules approved by the Namibia Financial Institutions Supervisory Authority (Namfisa) must be followed.
Hoffmann emphasises that any deviation from a rule requires Namfisa's approval and cannot be implemented unilaterally by the funds.
Absence of oversight
He also says fund rules do not expressly prohibit the payment of code 0210 either. The above action therefore clearly highlights the absence of effective regulatory oversight for medical funds and thus gives funds significant freedom to act without accountability.
Currently, there is no disciplinary framework that indicates specific sanctions against funds that act outside approved rules which, according to Hoffmann, shows a clear gap in the law.
Medical funds that refuse to pay bona fide claims in terms of Namaf's guidelines for its standard rates are acting outside their legal boundaries and must therefore be held accountable, Hoffmann said.
"Namaf's mandate to control, promote and coordinate medical funds and implement the necessary regulations has been neglected for 29 years. This enables funds to bypass the necessary regulation and supervision.”
He also refers to the Advisory Forum to which Namaf invited health practitioners for input and says it appears to be a mere marketing ploy that "appears inclusive on the outside, but which reinforces terms to the detriment of health practitioners and members and with financial benefits that go mainly to fund administrators flow".
"Assignments are included in fund rules, approved by Namfisa and imposed on members and health practitioners as fair and based on costs."
According to him, Namaf has allegedly collected more than N$5.9 million in authorised fees from health practitioners in the past three years. A request for a refund of the fees did not produce any response.
"The law approves funds to reimburse services based on rate codes, but does not give Namaf a mandate to enforce clinical control or diagnostic ICD-10 codes that are irrelevant to facilitating reimbursement."
Hoffmann says Namaf's insistence on ICD-10 codes violates patient confidentiality and violates international data protection laws.
"All recent Namaf mandates to funds, as well as those that come into effect on 1 January, should be set aside in favour of the status quo until the relevant legislation is enacted to protect the interests and rights of members and health practitioners." – [email protected]