Doctors’ group wants a commission of inquiry into Medscheme

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The Healthcare Practitioners’ Association said it was drafting a proposal to Health Minister Aaron Motsoaledi and President Cyril Ramaphosa asking for a commission of inquiry into medical administrator Medscheme, accusing it of non-payment of claims on the pretext of fraud investigations. The claims have been denied.

According to a Daily News report, Donald Gumede, the association’s chair, said doctors felt they were fighting a losing battle when they brought matters before the court.

He said doctors were accusing medical aids that fall under Medscheme of not paying out their claims, saying they were being investigated for fraud. They also accused the medical aids of spying on them by sneaking hidden cameras into their consulting rooms and undercover investigators posing as patients.

“The investigators would consult, complaining of vomiting or diarrhoea, and with no means of proving the patient’s claim the medical aid would withhold payment owed to the doctor, or demand payment already made to be returned, threatening to report the doctor,” Gumede is quoted in the report as saying.

He claimed the medical aids were “bigger than the law”. “We are busy drafting a memorandum to President Ramaphosa and Motsoaledi. It is about time that doctors exposed the bullying medical aids.” The report says these claims are contained in court papers the association lodged in the North Gauteng High Court in 2017 against 19 medical aid schemes.

Gumede said the association, formed in October 2016, had nearly 400 members nationally, 70 of whom were part of the High Court application. Gumede is quoted in the report as saying that some of the cases had gone to the Supreme Court of Appeal. “Each case cost as much as R1m – money doctors do not have because they are owed millions by medical aids. Many doctors have been forced to close their practices because the medical aids are determined to suck them dry.”

Dr Jimmy Mufamadi, a Gauteng occupational therapist who also runs a practice in Limpopo, is owed R1.1m by different medical aid schemes. He said he had been fined more than R880,000 although investigations had not found him guilty of any misconduct. He said he had been asked several times to provide patients’ files, but had refused every time.

“Patients’ information is confidential between them and me as a doctor. Medical aids may be entitled to information about the diagnoses, but not treatment and other details. I get victimised for refusing to disclose such information. We cannot work like this,” he said.

He said in the report that he had not taken his matter to court because none of the cases brought by other doctors had succeeded. He said black doctors were also being accused of charging too much. “It would have been a waste of money and time against filthy-rich medical aid schemes. We are being victimised because unlike the white doctors who own big homes to run their practices from, and do not have to pay rent so they can keep their rates lower, we from poor backgrounds have to factor rent into our rates,” said Mufamadi.

The report say the Educators Union of SA (EUSA) said it supported the doctors in their efforts to have a commission of inquiry established because its members were affected. EUSA general secretary Siphiwe Mpungose said they received many complaints from their members about doctors who required them to pay cash for consultations because doctors were “fed up” with medical aids.

Bonitas Medical Fund chief operating officer Kenneth Marion said in the report that Bonitas, one of the medical aids which falls under Medscheme, denied all allegations against it. He said fraud, waste and abuse (FWA) in the health-care industry were the main drivers of increased costs.

“Around 15% of claims in the healthcare industry contain some element of FWA, which is why in 2015 we introduced an analytical software programme to identify anomalies or irregularities that could be indicative of FWA. The software is a robust, analytical solution that detects irregular claiming behaviour both for claim types and service providers.

“All our investigations are done forensically, based on claiming codes and patterns. This is managed by an independent forensics team which uses data sets based on these codes which are not linked to the personal details of providers. All findings are evaluated fairly, ensuring that due diligence and corporate governance are upheld. At no time does the team have access to any doctor or service provider’s specific details,” said Marion.

He said in the report that it was therefore impossible to discriminate against or target one specific group of doctors. Once inconsistencies were identified, the case was handed over to the police and courts. “It’s the judicial system that determines if a practitioner is guilty or not. If found guilty, they are sentenced according to the law.”

Daily News report

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