The Independent Provider Association Foundation of South Africa (IPAF), a national network of family practitioners that comprises of SP Net, ASAIPA, NHC, SAMCC including KZNDHC, GMCC and CPC Qualicare, has released position statements on fraud as well as alleged racism by medical schemes.
Regarding its position on fraud, the IPAF said: "IPAF is against any form of fraud. Not only is this a criminal matter but also it leads to increased cost of care, which, in turn leads to private healthcare being unaffordable. As the leading national family practitioner doctor network, we do not condone fraud, and will not defend any of our members in instances where fraud has been proven beyond doubt. Secondly, we do not condone deviation from the law by medical schemes and administrators, in the name of recouping monies allegedly claimed fraudulently. Lastly, we urge our members to exercise care and caution when providing medical services and claiming from medical schemes for services rendered."
Regarding acknowledgment of debt, the IPAF said: "Doctors who are accused of fraud are frequently coerced into signing an Acknowledgement of Debt to a medical scheme by withholding of payment or paying the patients directly. This move affects his/her cash flow. These AODs in essence becomes a repayment plan of amounts allegedly defrauded from the medical aid. The amounts computed in these AODs are usually based upon small samples of evidence, which is irregularly assembled, unscientifically computed and frequently a thumb suck on the part of the funder who alleges that they have been defrauded. The doctor, for his part is intimidated by the process, is ill equipped to represent himself and to challenge or test the validity of the allegations, and is threatened by adverse publicity and reporting to the Health Professsionals Council of SA (HPCSA) and the SA Police Service (SAPS) should he resist signing the AOD. IPAF condemns the practice of signing AODs. Criminal matters have to be reported to the SAPS and unethical matters should be reported to the HPCSA.
"Section 34 of the Prevention and Combating of Corrupt Activities Act 2004 states that 'a person/practitioner suspected of involvement in fraudulent activity that involves an amount of R100,000 or more, should be reported to SAPS. Failure to comply constitutes an offense under the Act. In terms of SA law and our Constitution, any person is presumed innocent until proven guilty. Therefore, when investigating fraud, this right has to be recognised and respected at all times. Evidence needs to be laid before the doctor, and he must be given adequate time to consider it, and be reminded of his right to remain silent, as well as to representation by an attorney of his choice. Unfortunately, in some instances, the funders forensic units have used entrapment and thereafter coercion to embarrass the doctor into agreeing to their terms."
Regarding its position on patient confidentiality, the IPAF said: "Patient confidentiality should never be breached by a doctor. Funders usually request new applicants to sign consent for the fund to examine their patient records. It is however prudent for the doctor to request express written consent from the member or patient before submitting their clinical records to a funder or administrator. Patients’ rights to confidentiality is a fundamental human right and it is in the Ethical Guidelines of HPCSA (Booklet number 5). This right has to be respected at all times. They need to have express written consent from the member to access their clinical records.
"A doctor may divulge information regarding a patient under any of the following conditions: in terms of the statutory provision; at the instruction of a court; in the public interest; with the expressed written consent of the patient; with the written consent of the parent or guardian of a minor; and in case of the deceased patient – his next of kin who is in charge of the estate.
"If none of these processes have been followed, it would then be illegal for a forensic unit to demand patients’ records and unethical for a doctor to comply."
Regards raids of a practitioners’ place of work by the schemes’ forensic units, the IPAF said: "Investigators must be in possession of a Section 41 (a) warranty requested from the HPCSA and issued by a magistrate before they can search premises. Without this warrant, the doctor is within his/her right to request the investigators to leave the premises. Failure to comply constitutes trespassing."
Regarding its position on the medical schemes’ forensic units, the IPAF said: "We accept the fact that members’ funds have to be protected and the schemes and administrators have to ensure that fraud is eliminated in the industry. However, in terms of South African Law, any person is presumed innocent until proven guilty. Therefore, when investigating fraud, this right has to be recognized and respected at all times. What has been brought to our attention, as IPAF, is the disregard for the law and due process when investigating fraud. There are no set operational standards by which these units operate. There are no standards of minimum qualification or accreditation of these units, or their officers. Their only function is to recoup monies at all cost. In the process doctors’ rights and patient confidentiality is trampled on. There is no authority body that overlooks their function. They are a law unto themselves.
"The HPCSA has repeatedly requested that any doctor found to have behaved unethically or guilty of any fraudulent behaviour that brings the profession into disrepute should be reported to them to take disciplinary action. These units do not do this; rather they suggest non-disclosure and use that as leverage to coerce the doctor into signing an acknowledgment of debt.
"IPAFs position is that they need to be properly regulated so that they operate within the law. Secondly, doctors who break the law must be reported to the SAPS as well as the HPCSA and charged accordingly, rather than embarrassed into signing AODs in return for continuation of guaranteed payment by the funders.
We have a peer review contract with some medical schemes and administrators where we seek to reduce waste and abuse through formal peer reviews that are based on the profiled data that will show where there is suspected waste and abuse. Through these peer reviews, we are able to reduce waste and abuse. We are against any form of waste and abuse of medical resources."
Regarding its position on withholding payment to doctors or paying the patient instead of the doctor, the IPAF said: "Sechaba judgment (Section 59(2)): Direct payment to doctors rather than paying members: of the Medical Schemes Act does not afford schemes discretion regards whether they can pay the member directly and not the doctor for services rendered. The judge summed up this matter this way – 'When a member utilizes medical services and arranges for the provider to submit a claim to the scheme, they are authorising the scheme to pay the doctor directly and not the member'.
"Section 59(3) of the Medical Schemes Act 131 of 1998 MSA empowers the medical aid to recover any amount paid to practitioner wrongfully – misconduct by a practitioner. We accept this and are not against schemes recovering any money paid to the providers wrongfully.
"Practitioners should report to the CMS medical schemes that unlawfully withhold or delay payments as a result of alleged provider fraud."
Regarding its position on the alleged racism by schemes, the IPAF said: "We condemn any form of racism as this is against the letter and spirit of our Constitution. We are therefore concerned about the allegations of racism in healthcare and the alleged targeting of health professionals by schemes’ forensic units on racial lines. Racism of any sort is a serious allegation that warrants urgent attention by the relevant authorities. We are aware that the medical industry statutory bodies like the CMS, and the HPCSA are investigating this matter. We will await their reports on this matter and we will comment further if need be."
Dr Elijah Nkosi IPAF CEO
Professor Morgan Chetty IPAF chair