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Black doctors overwhelming racially profiled by medical aids

Gems and Healthcare Funders’ applications to interdict the release of report was struck off the roll.
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The Section 59 Investigation Panel has found that three medical aid schemes, Discovery Healthcare, Medscheme and the Government Employees Medical Scheme (Gems) have unfairly discriminated against black medical practitioners for eight years.

The Council for Medical Schemes (CMS) launched the Section 59 investigation following a complaint laid by the members of the National Health Care Professionals Association (NHCPA) and Solutionist Thinkers that their members were being racially discriminated against by medical aid schemes and administrators.

The NHCPA claims that the unfair discrimination also led to medical aid schemes and administrators withholding payments to their members, which directly impacts on the bottomline of their members’ businesses. This claim was supported by the The Health Professions Council of South Africa (HPCSA).

During his testimony to the panel, HPCSA president Dr Tebogo Kgosietsile Letlape said that the mechanisms used by the schemes to address fraud, waste and abuse (FWA) only affect black providers because they are dependent on the direct payment from medical aids.

‘Black’ in this instance refers to African, coloured and Indian race groups.

“The people from affluent communities are not affected by these issues. They have, you know, tap machines, swipe machines. You pay before you are seen, or you pay before you leave. They don’t have creditors. They don’t send accounts. And they are not impacted by this behaviour of medical aids,” he said.

The panel found that between 2012 and 2019, black medical practitioners were 1.4 times more likely than those not identified as black to have been classified by the three medical aid schemes to have committed FWA, which amounts to unfair racial discrimination.

The interim report released on Tuesday found that Discovery was 35% more likely to identify black providers as having committed FWA, Gems 80% and Medscheme 330%.

Although there is no unilateral definition of FWA, the CMS defines “healthcare fraud” as knowingly submitting false claims, or the misrepresentation of the facts in order to get payment of a benefit to which one is not entitled. The CMS defines waste and abuse as claiming healthcare treatment and services that are not absolutely medically necessary.

One example of racial profiling provided to the panel by the NHCPA was a ‘Black List’, which is published by Gems. It is a list of providers that patients should no longer consult after being blacklisted for allegedly committing FWA.

Ninety-four percent of general practitioners and 100% of social workers blacklisted by Gems were black, according to the interim report.

Speaking at the release of the interim report on Tuesday, the panel’s chairperson Advocate Tembeka Ngcukaitobi said that during the public hearings which were held from July 2019 to January 2020 some medical practitioners had complained of “sheer intimidation” by medical schemes, which in turn forced the black medical practitioners to accede to the demands of the medical aid schemes.

The panel heard that during investigations of FWA, the medical practitioners would be given minimal communication regarding the status of the investigation.

“This left providers in a position where they were being asked for information without any context or explanation about what it was the scheme was seeking to verify…. This vagueness made it difficult for the providers to respond,”the report found.

Every scheme and administrator that was implicated in the complaints denied that there was unfair racial discrimination in their FWA investigation process.

The medical aid schemes and administrators based their contestation of the interim findings either on an automated system, underpinned by an algorithm, that flags outlier practices for investigation or tip-offs and whistleblowers.

The schemes and administrators argued that only practice numbers are known by the automated system and there is no assignment or identification of race either explicitly or implicitly in the system.

The panel however found that even though the medical aid schemes and administrators use automated systems, there is always an element of human intervention at some point along the chain of investigation and that “the systems are not fully automated and therefore the FWA outcomes are not a product of only machines or their programmers.”

The interim report was released on Tuesday after the Gauteng High Court ruled that the interdict to prevent the report from being released by Gems and the Healthcare Finders be struck off the roll.

The application by Gems and the Healthcare Funders was heard on Sunday, with the organisations arguing that they had not been given an opportunity to view and respond to allegations levelled against them in the report. The interim report should not be released to the public, the healthcare groups argued.

Parties have until March 1, 2020 to provide the panel with their views on the interim report before a final report is released.

Read the full report here 

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Profiling? Really? I’d rather say that some groups are possibly far more likely to commit claims fraud. Whose fault is that then? Those who catch them out?

Must be the algorithms in the software that are somehow biased…

What exactly is the purpose of this article ?
It is an undeniable fact that Medical Aids need to vet claims.
It is an undeniable fact that some doctors take a chance – this is a fact.
Medical Aids must be careful with my money – that is a fact.

Boring.

Playing the divisive identity game. A bad move.

94% medical practitioners and 100% social workers – how is that divisive

Oh please. Write something with substance and of value…or rather publish nothing!

Just because a data set can be skewed along racial lines does not mean the data set was selected along racial lines. A more pertinent question would be to ask how many of the practitioners identified was eventually found to have lodged fraudulent claims? If a substantial quantity were found guilty the system works, if not it should be redesigned. Its as simple as that.

I am really getting tired of the equality issue in this country. The majority of nurses are women, does this mean we should bar women from nursing school and force men to join? The majority of convicts in prison are men, does this mean we should send innocent women to prison in order to obtain equality?

“The people from affluent communities are not affected by these issues. They have, you know, tap machines, swipe machines. You pay before you are seen, or you pay before you leave. They don’t have creditors. They don’t send accounts. And they are not impacted by this behavior of medical aids,” <<< What does he mean by this? That all practitioners of affluent areas are white? Must I now hold public hearings on the racist undertones of this claim? And must I write a report on this as well?

I think there is a critical point made in the article that could render the point moot. If you have two providers A & B. A decides only to accept cash, while B makes use of the medical aid’s process to recoup costs. A is not going to subject to the medical scheme rules or fraud verification because the medical aid is not paying them directly. Have the statistics been adjusted for the demographics of the group of doctors that claim from medical aids or the demographics of doctors in general?

BAYE’S theorem.

Black doctors overwhelmingly racially profiled! Really. I genuinely think South Africans need to start resisting unnecessary racial profiling. What was the actual race demographic surveyed? Should the findings fit the national demographics? You can torture anything to make a certain racial argument but this is getting a bit much.

@Daniel84.

Who are the social workers and medical practitioners? What identity group are they being placed in, in the article?

The article is about how one group of people are being profiled by another. This is identity politics.

Boy this victim card is played HARD in SA

It works, we get down on one knee 😉

@trader123

I agree 100%. We are very sorry. Shame, you’re excused. Now off you go & proceed as you were 😉

Horrendously poor maths to build the case. Because the outcome is more black doctors are found to abuse the system it must be racist, rather than taking the time to profile the factors that identify those that abuse the system (such as education, training, experience, practice support). Perhaps if we better identified the causes we could deliver a better health system for all. But they have that answer already – nationalise everything into the NHI.

This ISH is getting old real quick. Playing the race/victim card.

The medical aids choose to collect money for fraudulent claims from the perpetrator, rather than laying criminal charges with SAPS.

Why? Because their concern is to claw back the money; because – ironically – they don’t want to be accused of racial profiling; and because the police won’t investigate the case anyway.

In laying the complaints against the medical aids, which resulted in this inquiry, these dishonest providers of medical services are boasting of defrauding the medical aids.

They are criminals.

Having to refund the money they stole is “discrimination”.

Oh the humanity.

What the complainants are demanding too, is that they be allowed to get away with it, based on their pigmentation.

So is the bottom line, that the report points to racial profiling by the medical aids or that the majority of fraud is being committed by a specific racial group?

“The people from affluent communities are not affected by these issues. They have, you know, tap machines, swipe machines. You pay before you are seen, or you pay before you leave. They don’t have creditors. They don’t send accounts. And they are not impacted by this behaviour of medical aids,” he said

Why don’t the black Doctors also get those tap & swipe machines? Then, the people they serve on a daily basis will think twice about showing up to their surgeries for ailments that don’t need the services of a Dr.

Hmm, and I will bet you SARS will not prick up their ears to investigate this cash business. Bagman for the ANC Mob “Judge” Davis will be dead quiet.

A lifetime ago our firm did forensic work on the then biggest medical aid admin company’s data. Most everything has a code and there is in many cases a logic to that code. Male patients don’t often have hysterectomies and if procedure xxx.yyy takes 45 minutes you need to be a special doctor to complete more than 10 a day.

We rented space on Transnet’s mainframe and crunched data. The fraud was shocking. I can’t recall exact detail but we ended near 20% were at best errors or more likely outright fraud. The process was fairly simple. Catch impossibilities, flag the doctor. Randomly follow up apparently valid claims of that doctor. Hello Mrs Bloggs, we are calling to hear whether you are satisfied with Dr Doctor’s service. “I have no idea who Dr Doctor is”. “No, I went in for a filling not a root canal.”

Nowadays all of that checking can happen real-time and the administrators can be in real-time contact with the member. How do doctors still get away with this?

It is safe to say that, due to local demographics, most medical fund members are black. The black doctor can only claim on behalf of his patient, who most probably is also black. If the medical fund does not trust the ethical and professional conduct of the doctor, why does the patient trust the doctor? The patient trusts the doctor, not for his medical expertise, but rather for his “financial expertise”. The doctor and the patient collude to defraud the medical insurance.

This tells us more about those factors that the communalist system incentivises than what it tells us about black doctors per see. The communalist culture incentivises the “innovative” members of society who find themselves in a position of relative power, to exploit the system and abuse their position, to plunder the shared resource.

This is the only nonracial and nonsexist conclusion we can draw from the objective data-set that is presented to us. It proves that the communalist mindset incentivises plunder, but we know that already because the Zondo Commission provided all the proof.

And what do we do if the data proves to be correct?

Then Advocate Tembeka Ngcukaitobi will have egg on his face. This has nothing to do with demographics etc but rather dishonest business practices!

Start your own organisation

The moment journalist/politicians/ managers talk about race, you know they are out of their comfort zone and try to deflect attention away from their weakness.

Actually the real question in this article is what are the medical schemes up to. A family who surprise surprise is white is currently running the Discovery gauntlet where they have accused her of fraud, convicted her and told her to sign an admission of guilt form and pay back R1million without ever explaining what they were accusing her of.
Another family member received the same treatment only for Discovery to drop the case when they were told she was 70 and retired.
Both parties applying what they believed to be the correct ICD10 codes for patients they really treated at rates that are correct.
I think the racial profiling bit is a complete red herring. The real story is the unfair treatment by the medical aids of the Medical professionals to what end? An alcohol ban to cure Covid? They are trying to stamp our fraud by beating all professionals to death. Who is going to study medicine and treat us all?

After reading the article I think the headline is wrong. 🙂

According to your (medical schemes) algorithmic systems, Black doctors are more prone to defraud you, understood.

IF and only IF all is above board, an innocent profiling of doctors, why the interdict? Why pay exorbitant legal fees to prevent the public of knowing of how innocent and ethical you are?

Truth does not beget restraint of its disclosure!

The basis of coming to the authors conclusions seems to be clouded in puffery – where is the evidence of their sample size – how they conducted the study. Seems a case of raising the African flag of racialism to great effect

Kgosi Letlape, you should be ashamed of yourself for excreting this hogwash.

Yes, I am shocked at Dr Letlape for uttering such nonsense. He was a private medical practitioner himself. We have been running a private practice for 40 years and your “machines” won’t protect you against fraud. You have to, by law, provide the patient with a detailed accound, billed according to the prescribed codes. If the patient paid upfront, he or she sends in the claim for reimbursement to the medical aid. This account is still linked to the doctor who made the charges and if they are fraudulent, the medical aid will act. Letlape would have you believe that if a patient paid at the surgery, nobody claims from the MA. Why do people belong to medical aids then?

Thando, how after reading the report did you decide on this headline? It’s false and misleading.

From the evidence provided by medical aids (included in the report) race was not a consideration in profiling. The outcome of investigations, however, resulted in the real headline:

“Black doctors found to commit more fraud.”

I really do not understand the conclusion or implication here. The demographics of those doctors that commit fraud are mostly black, therefore the only conclusion must be the medical aids are racist? Has the world gone mad?!?!

Does everything have to fit a picture perfect racial demographic fairy-tale? Can you explain why Bafana Bafana are all black? Can you explain why the track and field and basketball athletes are mostly black yet only form 8% of the US population? Does this mean the system is racist – or rather that no demographic will ever perfectly present in any natural order. Why would it?

Either these black doctors committed fraud or they didnt. Only in South Africa would these statistical outcomes be considered racist! I hope this is appealed in the highest courts.

This is just the result of a survey some people don’t like.

I agree the article heading is misleading and sensational. This apply to the all media reporting on this. The only logical conclusion from the data presented is that certain demographic groups of health care professional are more dishonest than others. I am sure that is why the medical schemes did not want to release the report in the public domain. Now the facts are in the open and very informative.

Attacking the fraud evaluation processes of the scheme administrators is futile. There will always be “human intervention” and it’s impossible to prove that any human is not racially biased. It is a non-falsifiable conjecture. I know from personal experience I’m always struggling to prove I’m not a Witch, or at least not sympathetic to Witches, or all those in service of the Dark Lord.

Fortunately the solution to the former is glaringly obvious: Introduce race-based healthcare fraud quotas.

For every non-white professional you accuse of fraud you need to accuse the statutory minimum proportion of white professionals.

What could possibly go wrong with an outcomes based system such as this? Geesh guys do I have to think of everything?

Comment removed

In my opinion, it looks similar to CNN. I stopped reading after the first ten lines.

OK, so a computer objectively came to a conclusion ‘some’ people don’t want to hear.

But what about the issue that certainly does NOT belong in a non-racist society; The racist selection criteria when allowing medical students at university.

End of comments.

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