Medical schemes’ anti-fraud tactics queried at CMS inquiry

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Medical scheme administrators are overstepping the mark in their fraud investigations into healthcare professionals, straying into the terrain of regulatory authorities and claiming back money they have not proved they are entitled to, according to consultancy firm Elsabé Klinck & Associates.

Elsabé Klinck spoke to Business Live after giving evidence to the Council for Medical Schemes (CMS) inquiry into allegations that medical schemes unfairly target black, Indian and coloured healthcare professionals for forensic investigations. She said many medical scheme administrators claw back funds in cases of suspected fraud without substantive evidence, but in her firm’s view there has to be proof of fraud before money is reclaimed. The principles of administrative justice and the principles relating to the law of evidence must be applied, she said.


The inquiry has heard how Discovery Medical Aid recently “entrapped” a doctor into issuing fraudulent sick notes and then investigated him, reports The Star. Discovery also “tricked” two other doctors into submitting fraudulent bills, Yvonne Naidoo, a lawyer from Elsabé Klinck & Associates said at the inquiry. The scheme then turned around to inform the doctors that it had launched forensic investigations into their practices and withheld all money due to them, Naidoo said.

The doctors, who are all black, were then informed that in order to make their troubles go away they should enter into acknowledgement of debt agreements with the scheme.

The report says the inquiry chaired by advocate Tembeka Ngcukaitobi has previously heard anecdotes about alleged unethical conduct of schemes when probing doctors it accused of fraud.

Medical schemes will testify late next month, where they are expected to defend themselves.


The South African Optometric Association said that of their eight members who were investigated by schemes this year, seven were black, Indian and coloured and one was white. Eyewitness News reports that the association was presenting evidence at the Section 59 inquiry.

Association president Dollars Boloka said that there were 2,600 practicing optometrists in the country but it did not have the breakdown in race. However, consulting CEO Harry Rosen said that the majority of those they had assisted were black, coloured and Indian.

Business Live report
The Star report
Eyewitness News report

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