Namaf’s coding structure – the key to clinical risk management

The Namibian Association of Medical Aid Funds (Namaf) serves as the regulator of clinical risk within Namibia’s healthcare funding industry, as established by the Medical Aid Funds Act 23 of 1995.

Through implementing and administering a coding structure, Namaf plays an essential role in maintaining a sustainable and equitable healthcare funding system, benefiting all stakeholders – from medical aid fund members to healthcare providers.

What is Namaf’s coding structure?

The coding structure is a translation of medical terminology into a coded format.

This standardised system enables healthcare providers and medical aid funds to categorise and bill for medical procedures, diagnoses and consumable products.

In other words, it acts as a common language that facilitates consistency in how healthcare events are described, documented and paid for.

At its heart, the coding structure includes three types of codes:

• International classification of diseases (ICD) diagnostic codes to identify the diagnosis made by a healthcare professional.
• Procedure codes to identify the treatment provided – these codes link up to benchmark tariffs, which serve as guidelines for reasonable costs for medical services.
• National pharmaceutical product index (Nappi) codes to identify medicines prescribed by a healthcare professional and consumables used during treatment.

This system is the ideal structure that Namaf is in the process of introducing. To date, the procedure codes have been fully implemented, while ICD-10 codes are in Phase 1 of the implementation process.

Nappi codes will be introduced in the near future.

Once fully implemented, the coding structure will be used every time a healthcare event takes place, ensuring that each aspect of a patient’s journey – from diagnosis to treatment – is clearly recorded and billed.

As such, it is essential for the accurate submission, processing and payment of medical aid claims.

Clinical risk tool

Namaf’s coding structure acts as a clinical risk management tool, protecting the interests of healthcare providers and members of medical aid funds. Clinical risk, in this context, refers to the potential for financial loss or harm due to inefficiencies, errors, wastages and abuse.

The coding structure addresses clinical risk in several ways:

1. Accurate reimbursement: The coding structure ensures that the medical treatments a person receives are billed correctly. This helps prevent overcharging and ensures that medical aid benefits are used for appropriate services.
2. Tracking trends through data: The coding structure allows for the systematic recording of healthcare data, helping medical aid funds analyse trends and identify unusual patterns.

This enables informed decision-making and helps medical aid funds design benefits that better meet the needs of members, while allowing timely intervention when outliers or inefficiencies are detected.

Practice numbers

In accordance with the Medical Aid Funds Act 23 of 1995, Namaf issues practice numbers to healthcare providers, which they need if they wish to claim directly from medical aid funds. A healthcare provider’s unique practice number is linked to the coding structure by identifying the specific services the provider is authorised to perform and bill for.

This ensures that claims submitted are accurate and aligned with the provider’s qualifications. Practice numbers also help medical aid funds to track services back to the individual provider, enabling effective management of clinical risk.

Protecting private healthcare funding

Namaf’s coding structure is a vital tool for managing clinical risk within Namibia’s private healthcare system.

It ensures that medical aid fund members receive fair, accurate billing, and that healthcare providers are paid correctly for their services.

The system’s standardised codes, used in conjunction with practice numbers, provide clarity and transparency, preventing waste and abuse, and ultimately ensuring that healthcare remains accessible and affordable.

In this way, Namaf’s coding structure helps sustain a fair, efficient healthcare system, benefitting all stakeholders – from members relying on their medical aid fund, to healthcare providers, medical aid funds, and the private healthcare sector as a whole.

• Uatavi Mbai is Namaf’s spokesperson.