Doctors go to court over ‘spying’ but SA med schemes say it’s justified

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Doctors have brought a High Court action against SA’s biggest medical-aid schemes over ‘spying’ and ‘sneaking hidden cameras’ into their consulting rooms.

The Sunday Times reports that the healthcare practitioners also claim the schemes are guilty of withholding payment from doctors without proof of misconduct.

The report says these startling claims are contained in documents filed recently in the Pretoria High Court by the National Healthcare Professionals Association, in a claim against 19 medical-aid schemes. The association was formed in October last year and has 320 members nationally. Of these, 65 are part of the court application.

The association accuses the medical-aid schemes of acting like “police, prosecutors and prison warders”.

But the, the report says, the medical aids have denied any wrongdoing, saying fraud and false claims were on the rise and amounted to millions of rands a year. Most of the schemes said they would oppose the court application.

The report says the healthcare professionals association took particular aim at Discovery Health, which it accused of acting unconstitutionally by mounting probes in doctors’ rooms. It says Discovery has “over the years engaged in the practice of sending probes and/or spies and/or private investigators with concealed video cameras and recorders into the private consultation rooms of the applicant’s members without the knowledge and consent of the (doctor)”.

“It is submitted that this conduct . . . is unlawful and should be declared as such. This conduct . . . does not only infringe on the doctor-patient relationship, but also infringes on (doctors’) constitutional right of privacy, human dignity and freedom of trade, occupation and profession,” the papers read.

The body’s chair, Dr Donald Gumede, is quoted in the report as saying that among the spies reported to it was a woman complaining of vomiting and diarrhoea – which doctors say is difficult to disprove – as well as women bringing cases “designed to pull on doctors’ heart strings”, such as that of a young child who had allegedly been raped or was desperately ill. He said spies would also pose as parents and bring a child along for treatment.

The association claims in its court papers that medical-aid schemes are deliberately withholding money from doctors – or demanding that practitioners refund money already paid to them – over a “suspicion” that wrongdoing had taken place, even when the allegations were denied.

The association claims that section 59 of the Medical Schemes Act allows schemes to recover money only when theft, fraud, negligence or misconduct has actually been proven – but that this is not happening. It has asked the court to make a declaratory order that the act does not permit medical aids to withhold payment without proving their allegations.

Several of the doctors involved in the lawsuit said in the report that they were at their wits’ end. Attorney Dennis Sibuyi, who is representing the association, said: “We’re not suggesting they do not have the right to investigate . . . but we are saying they are abusing (the Act). We are saying they can’t withhold money while they are investigating. It’s killing doctors’ practices.”

But, the report says, Professor Alex van den Heever, chair of social security systems administration and management studies at the University of the Witwatersrand’s graduate school of public and development management, said medical schemes were justified in attempting to detect and address fraud by doctors. “They have large databases, which allow them to detect unusual conduct. In many instances this will be more than a ‘mere suspicion’, while nevertheless falling short of the evidentiary bar for a conviction,” he said.

Medscheme, which is an administrator for about a dozen of the respondents including Bonitas, said it had been notified of the case. “Medical-scheme claims are paid upon presentation and in good faith,” said Medscheme general manager for healthcare forensics Paul Midlane. “Claiming patterns and behaviour are only properly reviewed and validated retrospectively.”

The report says Midlane, who stressed he was commenting on behalf of Medscheme, not its clients, added: “When billing irregularities are identified, the provider is always given an opportunity to respond.”

Discovery Health CEO Jonathan Broomberg said: “Only a small minority of the over 20,000 health professionals commit fraud and billing abuse and we have a responsibility to deal with this actively.” He said investigations “adhere to the very strictest standards”.

Dr Gunvant Goolab, the principal officer of the Government Employees Medical Scheme, said schemes had to protect themselves.

Jeremy Yatt, principal officer of Fedhealth, said “irregular or over-claiming is costing the industry millions of rands every year and is on the increase”.

The Times report

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