Doctors say medical aid demand for diagnoses ‘violates ethics’

Doctors have accused the medical aid industry of undermining patient confidentiality by requiring patients' ICD-10 diagnostic codes to process medical claims.

ICD-10 codes are internationally recognised diagnostic tools developed by the World Health Organisation (WHO) to classify diseases, injuries and other health conditions.

The Namibia Private Practitioners Forum (NPPF) says medical aid funds require doctors to include ICD-10 diagnostic codes when submitting claims for reimbursement. Failure to do so could result in claims being rejected or delayed.

The NPPF, however, argues that compelling doctors to disclose patients’ diagnoses without explicit informed consent violates medical ethics, threatens patient privacy and could expose members to discriminatory decisions regarding their medical aid benefits.

In a notice issued to members and posted online, the NPPF said neither the Namibia Association of Medical Aid Funds (Namaf) nor medical aid funds have the legal authority to enforce mandatory ICD-10 coding.

“Practitioners will not comply with any ICD-10 mandate unless lawful authority is produced,” the forum said.

The NPPF argued that no law empowers medical aid funds to require ICD-10 codes as a condition for processing claims and maintained that valid claims must continue to be paid in terms of existing regulations.

Doctors who spoke to Namibian Sun acknowledged that ICD-10 codes serve a legitimate clinical purpose but expressed concern that the information could be used to profile members, assess health risks, and potentially influence future benefit design, premiums, or coverage for pre-existing conditions.

They further alleged that medical aid funds have tightened benefits while maintaining or increasing member contributions following the financial pressures experienced during the Covid-19 pandemic and fear that the latest requirement forms part of broader cost-containment measures.

Legal authority

The NPPF also questioned Namaf's role, saying the organisation lacks the legal mandate to impose the requirement, and called on the Registrar of Medical Aid Funds and Prosperity Health to provide proof of the legal authority supporting the move.

According to the forum, diagnosis information constitutes sensitive personal health information and compulsory disclosure without a legal basis threatens patient confidentiality.

The forum further argued that responsibility for obtaining patients' consent rests with medical aid funds rather than healthcare practitioners.

Additionally, it advised doctors, where applicable, to submit claims using ICD-10 codes U98.1 ("no practice disclosure") or U98.0 ("no patient waiver") and encouraged practitioners to report claim rejections or payment delays linked to the ICD-10 requirement.

Namaf defends ICD-10

Namaf has rejected the allegations, saying the mandatory use of ICD-10 is intended to improve patient care, strengthen collaboration across the healthcare sector and ensure the long-term sustainability of medical aid funds.

Namaf manager of stakeholder relations, Uatavi Mbai, told Namibian Sun this week that healthcare providers have always submitted clinical information through existing procedure codes when claiming reimbursement, and that ICD-10 complements those codes by providing internationally recognised diagnostic information.

"The diagnosis provides the clinical context for the treatment. Together, the diagnosis and procedure tell the complete healthcare story, allowing medical aid funds to reimburse claims accurately and design benefits that respond to the actual health needs of members," Mbai said.

She explained that while procedure codes identify the treatment provided, ICD-10 codes identify the patient's diagnosis.

"This is a diagnostic code. On the claim, they must write what the patient came in for. This will help medical aid funds ensure members' benefits are not depleted simply by paying for consultations without understanding what they are treating," she said.

Mbai said ICD-10 is internationally recognised as the global standard for disease classification, and Namibia has already adopted the system, while the health ministry prepares for the eventual transition to ICD-11.

She said diagnostic information enables medical aid funds to monitor disease trends, detect fraud, waste and abuse and develop benefits that better reflect members' healthcare needs.

"We want to know what doctors are treating patients for so that we can design better benefits and better protect the member," Mbai said.

She added that members authorise the sharing of relevant clinical information when joining medical aid funds.

Mbai argued that ICD-10 does not introduce a new concept of information sharing but standardises the diagnostic information accompanying reimbursement claims.

Full picture

Nevertheless, she encouraged healthcare providers to continue informing patients about how their information is used during the claims process.

Mbai dismissed suggestions that the information would be used to discriminate against members.

"The objective is to understand the health profile of our members so that benefits can be designed around actual healthcare needs, ultimately improving patient outcomes while protecting members from unnecessary financial risk," she said.

She added that the healthcare funding industry continues to face rising healthcare inflation, changing disease patterns and the lingering financial effects of the pandemic.

"Namaf tries to find a balance between what is affordable for the member and how the member is protected. Without members, the whole industry will collapse," Mbai said.

She also accused some healthcare providers of abusing the claims system by submitting multiple claims using generic consultation descriptions.

"If you were misbehaving in the darkness, you would not want the light to go on. We want to understand the real health picture of patients," she said.