The SA Society of Physiotherapy’s bid to scrap provisions in the Medical Schemes Act that enable schemes to recover claims paid in error would have a devastating effect on the industry if successful, a legal consultant to the Board of Healthcare Funders (BHF) has warned.
The respondents are the health minister; the Council for Medical Schemes (CMS); Discovery Health Medical Scheme and 20 others; and the AECI Medical Aid Society, better known as Medscheme, and 58 others.
SASP has asked the Gauteng High Court (Pretoria) to declare section 59 (3) of the Act unconstitutional and invalid, arguing it gives too much power to schemes and administrators because they both investigate and adjudicate claims suspected to be fraudulent or erroneous. It wants the power to decide on claim disputes between schemes and healthcare providers to be given to an independent party, and a review of six years of contested audits.
SASP president Lonese Jacobs said the schemes, rarely accurately quantified the amounts clawed back were using “bullying, unfair tactics and threats”. “The process they follow when they do claim back years after the fact is not fair and just. The scheme is acting as judge, jury and executioner and clawing back these monies without clear evidence that the billing was incorrect in the first place,” she said. Health practitioners were “forced” to sign admission of debt, with the medical schemes allegedly cutting off their claims or suspending their claims until they capitulated.
Business Day quotes legal consultant Debbie Pearmain warning that if SASP were successful in their application, “it would make the administration of medical schemes extremely difficult and perhaps even unworkable”. Section 59(3) of the Act gives medical schemes the power to recover claims paid to a practitioner that they are not entitled to, including claims sustained due to fraud and those paid out by mistake.
Schemes are obliged to pay claims within 30 days. “If section 59 (3) is done away with, then schemes would have to take longer than 30 days to process claims, because the level of scrutiny would have to be increased dramatically just for ordinary claims,” said Pearmain.
See more from MedicalBrief archives:
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HSF submits comments on the NHI and Medical Schemes Amendment Bills
South African medical schemes: the biggest winners and losers in 2020
Medical schemes' anti-fraud tactics queried at CMS inquiry