The Tribune

By AVA TURNQUEST and RASHAD ROLLE

Tribune Staff Reporters

THE Bahamas Insurance Association says it is "uncertain at this time" if private insurers owe revenue to the Public Hospitals Authority due to the PHA's inadequate billing system.

Health Minister Dr Duane Sands has said the PHA delivers as much as $40m in unpaid services, a hole he is aiming to plug. He has indicated the PHA will in the future be seeking revenue that historically it has been unable to collect, inclusive of "insurance revenue, National Insurance (Board) revenue, Road Act revenue and the co-pays that are gazetted by law that people have not historically been willing or able to pay".

BIA chairman Emmanuel Komolafe was asked recently what would be the implications of changing the PHA's billing system and introducing a new fee schedule.

"It is uncertain at this time, whether private health insurers have any current exposure to the Public Hospitals Authority," he said.

"If in fact that there is some exposure, we are unclear as to the extent of the same. It is also difficult to ascertain at this time what (if any) impact the proposed increase in fees by the PHA will have on insurance premiums."

Currently, as many as 87 percent of patients pay nothing for care at PMH.

"There are millions of dollars in services that are provided to insured patients which are neither billed nor collectable by the Public Hospitals Authority and primarily PMH in large part because we are unable to generate bills in the format required for the insurers to pay," Dr Sands said last week.

Noting private practitioners have staff that generate bills with requisite documents, Dr Sands said: "They will then code the bill with an international classification disease code and a CTT code. They will then attach the medical record, documentation as well as a signed release from the patient and so forth and so forth. All of those things will have to be done within a certain timeframe and has to be what we call a 'clean claim', so you have to put together all these moving pieces.

"PMH does not have a computerised billing system so suppose Rashad now goes to a hospital and he uses a dose of antibiotics, gets a CAT scan, goes in for an operation, etc, it may be three weeks, four weeks before a bill is generated. Then nobody could find the medical records and so you cannot then bill even though the patient has insurance and the service was provided. That statement that there is as much as $40m of unpaid services is reflective of the realities, the institutional capacity and the current services provided for which we are not able to benefit," Dr Sands said.

Most medical records at PMH are handwritten and many are difficult to find. Dr Sands said whereas incomplete documentation could cause ten to 20 percent of the bills of private medical providers to be rejected, for PMH this number could be as high as 80 percent or 90 percent.

PHA is in the process of building the necessary systems, but Dr Sands could not say when they will be operational, in part because the necessary skillset for operating the systems do not exist in the public sector at the desired level.

"In my private office, I have three people who can code and bill," he said. "They have to be trained, have to be able to translate a medical document into a certifiable bill. When you send a bill, you are testing that this bill is a reasonable reflection of the service provided, nothing more, nothing less. It's not the physician who is doing the coding. The staff has to translate a medical appointment to a code, 999070, 99071, all of which are different complexity visits but which charge out at different amounts. If I do an appendectomy, it is a simple appendectomy? Is it a complicated appendectomy? Because that determines what you can bill and if you get it wrong it is fraud. When you have a system like we have in The Bahamas which in the public health sector has not kept up with the requirements of the insurance companies, then you have all of these missed opportunities and all these missed opportunities translate into the revenues you need to run the facility."

Mr Komolafe said the BIA welcomes initiatives that would strengthen the public healthcare system.

He said the association would be happy to meet with the PHA as industry stakeholders with a view to collaborating on how to improve the quality of healthcare.

"It is also important to state that private health insurers take their responsibilities seriously and honour their obligations to policy holders as documented in the policy contracts," Mr Komolafe said.

"All valid claims that are submitted are paid within the timeframe specified by the policies."