The Board of Healthcare Funders (BHF) has rejected a report that found that medical aid schemes had unfairly treated black healthcare providers and practitioners.
The funders described the report as “flawed”, saying if allowed to stand it would open the door for runaway fraud and corruption in the healthcare sector.
BHF managing director Dr Katlego Mothudi said fraudulent claims, over-servicing, abuse of benefits and improper billing practices cost SA’s medical schemes around R30bn each year.
“These losses directly impact the contributions and benefits of 9.7-million scheme members, the majority of whom come from historically disadvantaged communities,” Mothudi said.
Yesterday, Adv Tembeka Ngcukaitobi, chairperson of the Section 59 inquiry, said the panel had concluded that the tool used by SA’s medical schemes to detect and punish fraud and waste was procedurally unfair and resulted in racial bias.
The inquiry reviewed practices from 2012 to June 2019 and the panel handed its report to health minister Aaron Motsoaledi.
The investigation was launched after public allegations in May 2019 by members of the National Health Care Professionals Association and Solutionist Thinkers.
At the time, they said that medical schemes and their administrators were withholding payments and targeting black medical practitioners unfairly.
In response, the Council for Medical Schemes (CMS) established an independent investigation panel to probe the allegations.
Ngcukaitobi said: “[…] in our interim report we found that there was unfair discrimination on the grounds of race, which was prima facie in breach of the Equality Act and in breach of Section 9 of the Constitution.
“We have gone to great lengths to explain the evidence [that] the panel assessed to decide if the fraud, waste, and abuse systems as implemented between 2012 to June 2019 [were discriminatory].
“In relation to the historic period 2012 to 2019, we have found that the schemes have not materially disputed the risk ratios that [were] calculated.”
Ngcukaitobi said the risk ratio is a tool that was developed to work out the likelihood that a black practitioner would be subjected to an investigation, a finding and a penalty compared to the the same happening to a white practitioner.
“We did not make legal findings about unfair discrimination in terms of Section 9 or the Pepuda [promotion of equality and prevention of unfair discrimination] Act. We only considered the facts, and the facts led us to one conclusion: the evidence of the risk ratios before us shows racial discrimination against black service providers by the schemes,” he said.