The biggest medical aid provider in the country Botswana Public Officers Medical Aid Scheme (BPOMAS) and the dental body have reached an amicable agreement following weeks of simmering tensions on the wake of Botswana Dental Association (BODEA)’s termination of contracts with the healthcare insurer.
In a fight that has been slowly brewing for a month now, things appeared to have hit a gridlock last week when BPOMAS said it stood firmly by its decision to implement the dental health risk management plan which had irked BODEA, forcing the dental body to terminate some contracts with the medical aid provider, resulting in some BPOMAS users instigating a petition for BPOMAS to reconsider the move.
BPOMAS said its October 14 decision that led to its tough rules were long coming based on developments that the medical aid scheme found alarming. Chiefly, BPOMAS says it was concerned about the rising costs, which some have been attributed to waste, abuse and in some instances possible fraud.
“Dental claims have on average increased by more than 18 percent per annum in the last five years which is more than double the increase in the rest of the Scheme’s healthcare costs,” BPOMAS said last week in a statement.
“Furthermore, as an industry standard, dental claims as a proportion of total healthcare costs for a scheme with a similar profile to BPOMAS is around 5 percent wile for BPOMAS it is currently in excess of 12 percent. Based on the current claims pattern, the Scheme’s dental claims are therefore those that are clearly not sustainable and calls for intervention.”
Through its dental health risk management plan, BPOMAS says through this intervention, all legitimate claims will continue to be paid in full as per the Scheme rules, but they will not pay claims which they deem to be illegitimate.
As soon as BPOMAS implemented its plan last month, BODEA notified the public that it has terminated its service provider contracts with the medical aid provider, following the enforcement of stringent requirements on dentists dealing with BPOMAS’ over hundred thousand scheme holders. The dentistry body said the new regulations were not only tedious and unnecessary but had strong implications for the patient and threatened BODEA’s autonomy.
Chiefly among the concerns is that dentists fear their ability to expeditiously interfere in emergency situations is seriously curtailed as they must do pre-authorisation request before they can help. Moreover, BODEA explained that some of the restrictions will result in increase of wrong diagnosis, with some dental and oral diseases remain untreated.
Last week, BPOMAS users expressed support for BODEA’s move, expressing shock at the medical aid’s decision to enforce the start of “treatment pre-authorisation”, which was accompanied by a detailed dental operative manual that outlines clinical procedures, investigations, and dental materials which were to be excluded, restricted or pre-authorised by the scheme.
The medical aid members showed support through an online petition that was heavily circulated to get other members in pressuring BPOMAS to consider some of the restrictions pressed on the dentists, which led to the current stalemate. In a stinging statement contained in the petition note, the petitioners say the pay heavy subscriptions only to get poorly rendered services.
Still, BPOMAS’ last week showed no signs of bowing to pressure, explaining that not all BODEA members have terminated their contracts with the medical aid provider, and referred their scheme users to the list of dentists that still accept the medical aid without upfront payment.
“Members are however free to consult dentists who have terminated their contracts with BPOMAS and would be eligible to claim from the Scheme in line with the rule,” part of the BPOMAS statement said.
Now in a sudden turn of events, BPOMAS this week said following engagements with BODEA over terminated contracts, it has been agreed with immediate effect that the dentist will resume normal routine of servicing BPOMAS members and their dependents without requiring up-front cash payment.
However, the giant healthcare insurer reiterated that the dental health risk management programme will remain place, thus certain dental services that did not require pre-authorization previously, will now need permission from the medical aid provider.
In a sweetener for BODEA which was concerned that pre-authorisation of some otherwise routine procedures might have a negative effect on the quality of their work, BPOMAS has assured them that pre-authorisation requests will be responded to within a maximum of 24 hours, while emergency cases will not be subjected to pre-authorisation requirements.
