GOVERNMENT’S Health Insurance Plan (HIP) has come under attack by doctors who claim they are receiving lump payments months in arrears and without the necessary documentation for verification.

And they are questioning a new initiative placing Medical Clinic patients on the HIP scheme, saying it is unlikely they will be able to afford the associated costs.

At present, the clinic’s patients are not charged for treatment — however, once the facility closes, such persons will incur 20 per cent of medical costs in accordance with the Government scheme’s regulations.

“They had 100 per cent coverage at the clinic. HIP only pays 80 per cent, there’s still 20 per cent remaining. Who’s going to pay for it?” one local practitioner demanded.

“The programme doesn’t work now. Doctors aren’t being paid on time as it is. How is this extra paperwork going to affect the payment process? Will it just add further strain to the system?”

The doctor said the problems had been going on for a decade or more. He added he was slightly sympathetic towards HIP staff as it was his understanding the department doesn’t have a computer system, but those feelings were balanced by the vast displays of “incompetence”.

“Government is no longer reconciling HIP payments,” he said. “It’s public knowledge — or it should be. It’s something (the Auditor General) Larry Dennis has pointed out in his report over the years.

“Doctors submit an application for payment and every now and then Government sends a lump sum — which isn’t itemised. There’s no account number or patient listed.

“It’s gotten to the point that some doctors are proposing to do what the dentists do, to tell their clients they have to pay up front and collect the money back from HIP.”

Questions to Health Minister Philip Perinchief were not answered by press time.

In his Annual Report for 2004, the Auditor General highlighted several concerns with the financial reporting of the Hospital Insurance Fund which manages HIP, stating it was three years in arrears and that he could not offer a qualified audit opinion because he had “insufficient documentary evidence” to investigate claims.

“Antiquated and manual accounting systems, inaccurate and incomplete accounting records, and missing supporting documentation all contributed to audit difficulties,” the report stated.

“Another major factor was management’s consistent inability or unwillingness to provide requested information and documentation promptly.

“If the affairs of the Fund were managed properly, this information would be used to verify the Fund receives all the premium revenues to which it is entitled, and that claims are paid only for eligible patients and for medical services covered by the policies.

“In practice this cannot be happening to any great extent. The Fund’s records of group policies are maintained manually and listings of people covered are not updated regularly.”

The Auditor General continued to express such concerns in subsequent reports, stating that the weakness in financial reporting left the Fund vulnerable to fraud.

“The breakdown in the Fund’s accounting systems has now begun to affect the operations of local businesses, and people insured by the Fund,” he stated in the 2006 Annual Report.

“Medical service providers are not having their claims paid promptly and are not receiving itemised breakdowns when their claims are paid. The Bermuda Hospitals Board, for example, cannot allocate the claim payments it receives to the accounts of the patients on whose behalf the claims were submitted.

“I have anecdotal evidence that some medical service providers have begun billing patients directly, rather than having to wait for their claims to be paid, and even then being unsure which claims the payments cover.

“This is an unnecessary inconvenience to both medical service providers and to people insured by the Fund. And all because management of the Fund has accounting systems that cannot process claims promptly, that cannot provide details of claims paid, and also cannot produce timely financial statements for audit.

“Considerably greater effort and commitment by management will be needed to bring the financial accountability of the Hospitals Insurance Fund up-to-date.

“I have stated in previous annual reports that although financial statement audits are not designed to detect fraud, they can deter fraud. When financial statement audits are as far in arrears as those of the Fund, this deterrence is lost. “Weak internal and accounting controls and delayed audits create opportunities for misappropriation and fraud to occur and remain undetected.”

Yesterday, a doctor said massive outcry over the situation had been slowed by ongoing negotiations and a promise that it would improve once computers were installed.

“For a Government health plan to be in this sort of state . . .,” he sighed. “We’ve actually been in negotiations — probably primarily with HIP and the way they’re dealing with the claims — for a while.

“We’ve been promised the situation is being addressed. Everything had been done manually but they’re now putting in a computer. We’ve had payments that go back as far as 18 months.

“What happens then, is that you get paid in a lump sum — and without knowing what you’re being paid for. How are we supposed to properly reconcile our accounts?”

It made it difficult for doctors to determine whether they were in fact receiving the full payment for the work done, he added.

“Especially because (HIP is) limited in what they pay for certain procedures. And if the payment is two years behind, we can’t go to a client and ask them to pay the shortfall.

“But the biggest problem is more often than not, we don’t know what we’re being paid for. Last year we wrote a letter to HIP saying we needed to get to the root of the problem.

“Basically, if an independent physician calls and complains enough, they will get an itemised cheque but most of us are forced to wait. So of course we’re upset but we’ve been reassured it’s being addressed.

“It’s one of those things which is an upstream swim unfortunately. Government needs to get things shaken up and do what is right. Something needs to be done about it. They’ve got to get their act together.”

HIP: Red tape and overdue payments