Discovery Medical Scheme has testified at a Council for Medical Schemes inquiry that its “disproportionate” investigations into black professions did not conclude that there was “racial bias” on its part.
Business Insider reports that the insurer has denied racial bias in its fraud, wasteful care and billing abuse investigations after it emerged that it investigates more black health professionals than white ones. Discovery instead said the high number of black investigations was influenced by the high number of external tip-offs, representing more than 60% of all investigations in 2018, received.
It emerged at the hearing that 55% of Discovery's FWA investigations are on black health practitioners, while they only represent 37% of claims. In a video clip released by the SABC, Discovery Health CEO Jonathan Broomberg said: “When you look at the outcomes of the investigations process itself, how many cases turn out to be valid, what percentage of cases turn out to be valid, the numbers are exactly the same between black and white practitioners.”
In a statement to Business Insider South Africa, Discovery estimated that in the absence of effective fraud control activities, R1.7bn of member’s money would’ve been lost. It said aside from external tip-offs, it uses statistical analysis with 30 independent metrics which never includes demographics of health professionals.
Discovery reiterated that its analysis found that once an investigation is initiated, the proportion of investigations that lead to valid findings and to the recovery of funds show no differential by race. This sentiment was shared by statistician, Dr Zaid Kimmie who was appointed by the CMS to investigate Discovery. “This clearly demonstrates that once cases are identified for investigation, there is no evidence of any racial bias in the investigation process itself,” Discovery said.
Chair of the Section 59 investigation Advocate Tembeka Ngcukaitobi wanted to know why only black practitioners are likely to be investigated. “Is your submission that black doctors are more likely to be identified as fraud waste and abuse cases because they are trying to commit fraud in the process of trying to help poor people?”
SABC News reports that in his response, Broomberg said: “I don’t think I can go so far as to say that either than to say that it is possible that when you look at the doctors who are serving the relatively lower income families within medical schemes, it is possible that a higher proportion of those doctors are black.”
Dr Donald Gumede from the National Health Care Professionals Association, which raised the issue of racial profiling, believes the truth is finally coming out. “I would be happy if that gets corrected with strong recommendations because I believe that medical aids just made this fraud and waste and abuse a business and it shouldn’t be. If there is a crime that is committed you should try to prevent it and stop it, but I believe that the means that they have been using it as means to create criminality, which is not good.”
Eusebius McKaiser said on his talk show on 702 that he was not convinced by the reasons given by Broomberg over discrimination of black medical practitioners.
“Firstly, Discovery Health needs to be reminded of the history of the country. They initially denied that black medical practitioners were disproportionally targetted. The first problem for Discovery Health is why initially you made a hasty false claim, a denial, without asking yourselves: 'Are the anecdotal experiences accurate before rushing to say black medical practitioners are disproportionally targetted?'
The report says Broomberg called into the show to answer some of the questions raised by Eusebius. He said it would not be business as usual at the medical insurer.
“I made it clear to the inquiry that we are not perfect and we have a lot to learn about making the process fairer. At the same time, we have a responsibility to our members to protect their funds,” Broomberg said.
[link url="https://www.businessinsider.co.za/discovery-investigates-more-black-health-professionals-that-white-ones-2020-1"]Full Business Insider South Africa report[/link]
[link url="http://www.sabcnews.com/sabcnews/discovery-health-admits-its-systems-are-prone-to-flag-black-doctors/"]Full SABC News report[/link]
[link url="http://www.702.co.za/articles/373613/eusebius-discovery-health-explanation-of-discrimination-claims-not-convincing"]Full 702 interview[/link]
[link url="http://www.702.co.za/articles/373562/listen-discovery-health-responds-to-section-59-inquiry-into-racial-profiling"]Discovery’s response[/link]