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GEMS to claw back over R100m ‘defrauded’ by private doctors and hospitals

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South Africa’s biggest medical aid scheme has begun legal proceedings to claw back millions of rand fraudulently lost to scores of private doctors and hospitals, The Star reports. Money that the Government Employees Medical Scheme (GEMS) sought to recoup from private practitioners could amount to over R100m. The money was lost to syndicates of practitioners that claimed from GEMS fraudulently between 2012 and 2019, according to Ishmael Mogapi, the scheme’s operations risk manager.

The report says Mogapi was part of GEMS representatives who appeared at the Council of Medical Schemes (CMS) inquiry probing allegations of racism black doctors were said to have suffered at the hands of medical aid schemes.

Gems told the inquiry that it, fell victim to scores of unscrupulous practitioners operating in syndicates. It assured the panel that few doctors would accuse it of racism, adding that Gems paid out claims and only recovered the money after it satisfied itself that the claim was fraudulent.

Gems incoming principal officer Stan Moloabi said, “We do not use cameras,” Moloabi said, referring to the clandestine way of gathering damning evidence against doctors that other schemes allegedly applied.

The amount that Gems believed was fraudulently paid out to practitioners and hospitals jumped from R812 000 in 2012 to R86m in 2016. The 2015 figure was R68m, Mogapi revealed. A rehabilitation hospital in Malvern, Durban, paid Gems the R12m it had fraudulently claimed, the scheme said.

Full report in The Star (subscription needed)

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