The National Healthcare Professionals Association last year launched a Pretoria High Court action regarding the withholding of payments to doctors. In response, medical scheme administrators have highlighted the prevalence of cheating.
The Sunday Times report that the legal battle between the two groups being fought in the High Court in Pretoria cites several cases of apparent cheating by doctors – including one who said his financial records had disappeared in a flash flood.
The National Healthcare Professionals Association launched the action last year, accusing medical aid schemes of wrongfully withholding payments to its members. Doctors, therapists and pharmacists represented by the association say they are being bullied by the “vigilantism” of medical aids.
But, the report says, the medical aid administrators, representing nearly 20 schemes, have given details in their responding court papers about why they acted as they did in specific cases. For example, Centurion GP Dr Gene Ramontja is accused of hiring an unqualified “doctor” for four years to treat his patients, while claiming more than R1m from medical aid schemes. According to the court papers he “admitted the contravention” and signed an acknowledgement of debt to Medscheme, an administrator for multiple medical aids.
The report says Ramontja, who remains registered with the Health Professions Council of South Africa, did not respond to queries.
Also still practising is Dr Edwin T Mabuza from Limpopo, who Discovery alleges defrauded the scheme of more than R1.1m up until April by claiming for medicines he did not dispense. Discovery Health refused to pay him for treating its patients for six months, almost forcing him out of business.
He was asked by forensic investigators to prove he owned the ultrasound machines he said he used to treat patients, and to provide invoices for medicines he bought and dispensed. The report says he explained his invoices for the medicines had been “washed away in a flash flood”. He was told he could get duplicates from the supplier but he said the “supplier had absconded in the night”, according to the court papers.
Mabuza is quoted in the report as saying that nothing he gave Discovery would satisfy the company and he felt “victimised” because it had audited him three times. He denied having committed fraud. He said he felt black doctors were being racially profiled. “Are all white doctors honest?”
Discovery Health has blacklisted Johannesburg doctor Maidi Teffo, who it describes in the court papers as “a high-risk” and “habitual offender”. According to the papers, Teffo signed an acknowledgement of debt to the tune of R120,000 in 2008 after claiming for items not dispensed to patients. Five years later Teffo acknowledged debts of R920,000 after he was found to have claimed for much more expensive items than he had actually dispensed.
In April last year Discovery Health asked him about claims lodged since 2013 totalling R644,824 that it suspected were irregular. Teffo is quoted in the report as saying that talking about Discovery Health “made him depressed” and denied wrongdoing. He refused to comment further on the advice of his lawyer.
Medscheme and Discovery Health say they only do audits on “outliers” whose claims are flagged by sophisticated forensic software. The report says the software picks up doctors who claim significantly more than similar doctors do, health workers who dispense large amounts of unusual medicines, and those who treat patients for more than 24 hours in one day.
Discovery Health CEO Jonathan Broomberg said no doctors were targeted unfairly. “Discovery Health identifies potential fraud mainly through the use of sophisticated algorithms to analyse claims patterns. We do not use race, gender or any other demographic factors in our investigations.
“We only take clear action, including withholding payments, where there is proven evidence of fraud, and then only after full engagement with the provider and their advisers.”
The report says the court case resumes next month.
[link url="https://www.timeslive.co.za/sunday-times/news/2018-07-14-court-case-reveals-why-medical-aids-distrust-some-doctors/"]Sunday Times report (subscription needed)[/link]