Understanding medical aid tariffs

A medical aid fund is a non-profit entity registered and governed in terms of the Medical Aid Funds Act, 1995 (Act 23 of 1995). Medical aid funds are regulated by the Namibia Financial Institutions Supervisory Authority (NAMFISA). They are also members of the Namibian Association of Medical Aid Funds (NAMAF), the controlling body for medical aid funds in Namibia.

On an annual basis NAMAF publishes tariff codes and benchmark tariffs for specific healthcare treatment, services and procedures performed in- or out-of-hospital. These tariffs are only a guideline for any healthcare provider (including GP’s, specialists and anaesthetists) to follow when they consider billing the portion for which the medical aid fund will be accountable in respect of treatment provided.

What does ‘100%, 225%, 80%, and 50% of NAMAF benchmark tariff’ mean?

First of all it is important to understand that reference to a benchmark tariff does not limit or restrict the healthcare provider in any manner whatsoever to charge more than what is indicated as the NAMAF benchmark tariff. To the same extent a healthcare provider is not limited or restricted to charge less than the NAMAF benchmark tariff. The NAMAF benchmark tariff is a guideline tariff used by the medical aid fund indicating the maximum rate at which the medical aid fund is willing and able to reimburse for the services charged.

Reference is made in your opted benefit structure to services being covered at either 100%, 80%, 50% or 225% of the NAMAF benchmark tariff, which indicates the intent from the medical aid fund to reimburse specific claims only up to the limit as indicated in the percentage stated. As noted above it does however not limit or restrict the provider to charge in excess (or less) of the benchmark tariff as stated in our Benefit Guide. Therefore 100% of the NAMAF benchmark does not necessarily represent 100% of the cost of treatment as may be billed by the provider.

Should the healthcare provider charge more than the stated benchmark tariff then any excess portion of the account will be for the account of the member. Such co-payment will be recovered by the healthcare provider from the member directly either through an upfront payment or down payment.

Split billing

Split billing is defined as an instance where a healthcare provider collects a certain amount from the patient/member in cash and then bills the medical aid fund the balance of the account at the Fund’s benchmark tariff. Thus this cash payment is not reflected on the member claim and thus also not reflected as a member payment.

This implies that the value of the service is undervalued and the cash payment is not reflected on the claims invoice submitted to the respective medical aid fund and/or reflected as a member contribution. Whilst the Fund is not incurring any loss by paying out the same or claimed amount, the transaction is undervalued and thus distort the Fund’s data used for actuarial projections. NHP does not regard split billing as an acceptable way of billing.

In the event of the healthcare provider charging more than the benchmark tariff an invoice must be provided to the member clearly indicating the amount charged to the medical aid fund in respect of the benchmark tariff and the amount to be charged to the member in respect of his/her member’s portion.

It is important that members insist that all invoices provided contains the split in monetary amounts per tariff code used. All accounts for treatment rendered must be submitted in this format to the medical aid fund.

Should the healthcare provider insist on an upfront payment, where he/she charges in excess of the NAMAF benchmark tariff, without clearly specifying the payment received under the member’s portion, then such account is commonly referred to as a split bill as explained above. Split billing is deemed to be an undesirable practice since it can also be used for tax avoidance purposes. Furthermore the practice of split billing creates a false impression with the medical aid fund on submission of the claim that the healthcare provider is actually charging in line with the NAMAF benchmark tariff whilst in reality the actual cost of treatment is much more.

Members are encouraged to report any instances of split billing to either their medical aid fund who in turn will report it to NAMAF for onward reporting to the Health Professions Council of Namibia (HPCNA). In the alternative members may also lay a complaint directly with the HPCNA.

Split billing is a contravention of the ethical code of conduct of a healthcare provider in terms of the HPCNA.

Important for members

The most important thing for you is to make sure of the benchmark tariff or rate at which your benefit option covers your medical treatment and up to what limit.

If your Fund covers you at the normal 100% NAMAF benchmark tariff, you will have to negotiate tariffs with the service provider if they charge you more than the benchmark tariff. Failing to do so will result in you having to pay the difference out of your own pocket.

But surely 100% is, well, 100%? Not necessarily. If, for instance, your service provider charges at 300% of the NAMAF benchmark tariff and you are only covered at 100% (NAMAF benchmark rate), you will need to pay the difference. That is why many people accuse medical aid funds and ask, “Why are you not paying for everything?” The fact is that members often do not take the time to enquire about the meaning of the benchmark tariffs with further failure to enquire with the provider the rate at which he/she will be charging.

The first way to prevent such a shortfall is to get a quote from the service provider who will be performing the procedure. When you call NHP for pre-authorisation, ask how much they will pay for the procedure according to the benchmark or guideline tariff. You are advised to then go back to the service provider and negotiate a tariff closer to what you can afford or which is more aligned to the payout rate of the medical aid fund.

The Fund offers an additional in-hospital cover for services rendered whilst in-hospital (GAP cover) which provides cover of up to 225% of the NAMAF benchmark tariff for hospital procedures whilst in hospital. Any portion of the claim which is in excess of the 225% will be for the members pocket. Members will remain responsible for settling the full account to the healthcare provider and as such may be required to settle any outstanding amounts. It is the members responsibility to familiarise themselves with their benefits and levels of cover for which they qualify.

Should you need further information, please contact NHP for further assistance.

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