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NHCPA to launch class action suit against medical aid schemes

Following the release of the Section 59 Investigation Panel interim report.
Image: Shutterstock

The National Health Care Professionals Association (NHCPA) says it will launch a class action lawsuit against medical aid schemes following the release of the Section 59 Investigation Panel interim report, which found that there was “systemic discrimination perpetrated over a number of years,” against black medical practitioners by three healthcare groups.

Read: Black doctors overwhelming racially profiled by medical aids

The Council for Medical Schemes (CMS) launched an investigation in 2019 after members of the NHCPA and Solutionist Thinkers made allegations that their members were being racially profiled, harassed and bullied by medical aid schemes. The two organisations also alleged that medical aid schemes would demand confidential clinical information regarding patients and would withhold payments.

Chairperson of the NHCPA Dr Donald Gumede told Moneyweb that the lawsuit will seek to compel the three medical aid schemes implicated in the report – the Government Employees Medical Scheme (Gems), Medscheme and Discovery – to financially compensate the black medical practitioners who have been affected by the “unfair discrimination.”

“We have suffered financially and we need justice to [prevail]…we are prepared to go all the way to the Constitutional Court,” he said.

Gumede said the lawsuit will likely be launched once the panel completes its final report into the matter. The final report is expected to be released later this year after interested parties have submitted their comments on the interim report by March 5.

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

If found guilty of FWA, the panel found that the medical aid scheme will place a hold on the claims of the medical practitioner or refer the provider to one of the regulatory bodies for further investigation.

“The scheme may [also] decide to blacklist the provider. This means that the
administrator will no longer pay that provider, and will advise its members that
such provider [is] blacklisted,” the report says.

The panel found no evidence of explicit racial bias in the algorithms and methods schemes and administrators used to identify healthcare practitioners who had potentially done wrong.

However the panel found that, “using the data that Discovery, Gems and Medscheme provided the panel and its experts, there is a substantial difference in FWA outcomes between black and non-black practitioners over the period January 2012 to June 2019.

Black practitioners (including African, coloured and Indian people in this instance) were 1.4 times more likely to be classified as having committed FWA than those identified as not black.

Read the full report here

Medscheme, Discovery and Gems have all raised concerns about the interim report’s findings.

In a statement, Medscheme executive director Dr Lungi Nyathi said that the company had not been given the opportunity to view the interim report before it was released for public comment. However, Medscheme would be reviewing the contents of the interim report and making a formal submission in response.

Gems, whose application to prevent the release of the report was struck off the roll by the Pretoria High Court on Tuesday said it had “nothing to hide”and supported the panel throughout its investigations.

Discovery echoed similar sentiments to the other two healthcare groups, saying in a statement that the panel reached its conclusions “despite the fact that there was no specific evidence of even a single case wherein the methodology or approach to the identification and investigation of the FWA matter has been found to be inappropriate.”

“Whilst we don’t accept any racial discrimination in our processes, we accept and respect the panel’s recommendations and will endeavour to work hard within the healthcare system to ensure that going forward, outcomes are more satisfactory, balanced and representative,” it said.

The Health Professions Council of South Africa (HPCSA) has welcomed the interim report. In its recommendations, the panel said both the HPCSA and the CMS should assist the schemes to address FWA fairly and reasonably.

HPCSA chief executive Dr Munyadziwa Kwinda said that the organisation would not be providing any more information to the panel other than what it had previously submitted. Kwinda however said the HPCSA welcomes the recommendations of the panel and would implement them.

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As a reporter, your job is not just to regurgitate a PR statement or report, it is to investigate and scrutinize it.

Let’s scrutinize some of the statements:

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

> “more likely to identify”? … The outcome of investigations proved that black providers were more likely to commit fraud. How is this “unfair discrimination”?

2. If found guilty of FWA, the panel found that the medical aid scheme will place a hold on the claims of the medical practitioner or refer the provider to one of the regulatory bodies for further investigation.

> If a provider was found guilty of fraud, they were not paid and they for referred for investigation. How is this “unfair discrimination”?

3. “The scheme may [also] decide to blacklist the provider. This means that the administrator will no longer pay that provider, and will advise its members that such provider [is] blacklisted,” the report says.

> If a provider was found guilty of fraud, they were blacklisted. How is this “unfair discrimination”?

4. The panel found no evidence of explicit racial bias in the algorithms and methods schemes and administrators used to identify healthcare practitioners who had potentially done wrong.

> The panel, according to its own findings, found no evidence of racial basis.

5. All of this is done via AI software using the practice nr. ( the race of the practitioner is not yet know at this stage by the “machine”? ). Suspicious transactions are flagged and investigated and only now a “face” can be linked to the practice nr. when confronted by forensic investigators.

Ai (algorithms) is not human therefore does not discriminate

If the shoe fits, wear it

So Medical Aids are jittery now

They’ve out Ai aside for a wee while and probing the minority groups..It is of course the politically correct thing to do in SA

If black providers are guilty of FWA then obviously it is the fault of White Monopoly Capital.

Sounds like one of those old adages; “making a mountain out of a mole hill”. What these medical aid companies should do is institute criminal proceedings against these doctors. I wonder if ethics has a role to play in this scenario or is it just more greed by those trying to bleed the country and businesses of funds

The report proves that the doctors of colour were more likely to be corrupt. That is not racist but proof of corruption.

and these corrupt doctors are actually cutting the throats of the really innocent and hardworking ones.

This is just more proof that, in general, sewage sludge comes out of learned minds (usually academia).

Everyone seems to forget that Fraud, Theft, Lies and Looting are perfectly legal in SA.
How dare medical aid firms not condone it !!!

End of comments.

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