The Council for Medical Schemes (CMS) says it hopes its
probe into allegations of unethical conduct by medical schemes against medical practitioners
will solve the issue once and for all. The Council announced last week that it
will appoint a steering committee to investigate complaints of racial profiling
blacklisting for payments, blocked payments, demands of confidential clinical
information, bullying and harassment, coercion, entrapment and use of hidden
The medical practitioners, all members of the National
Health Care Professionals Association (NHCPA) have alleged that they were being
unfairly treated and their claims withheld by medical aid schemes based on the
colour of their skin and ethnicity. Both SAMA and the BHF have denied that they
have proof of racial discrimination but have welcomed the investigation, saying
that they condemn such conduct in the strongest terms.
In a statement, SAMA chairperson, Dr Angelique Coetzee said
the Association is committed to playing a significant role in the steering
committee and has urged anyone with proof of wrongdoing to provide it to the
investigators. She added that SAMA concurred with the view that Section 59 of
the Medical Schemes should be reviewed and updated to protect medical practitioners
as well as patients.
“In the context of National Health Insurance (NHI), we are
also researching the possibility that medical practitioners claim directly from
the Fund for work performed, rather than work through a middle-man for these
payments,” Dr Coetzee said.
The steering committee, to be chaired by the CMS, will
consist of two doctors with a forensic background, a health actuary, project manager,
medical ethics specialist, legal specialist, legal reform specialist, forensic
compliance specialist, data analyst and a communication specialist.
“We have listened to the complaints and allegations
presented in public platforms and we sympathise with the plight of the services
providers. We have also listened to the responses from the schemes and
administrators,” said Dr Clarence Mini, Chairperson of CMS. “It is important to
note that our regulatory actions are based on the Medical Schemes Act which
empowers schemes and administrators to undertake specific actions to protect
member assets from fraudulent, wasteful and abuse claims. The overall purpose
of this section of the legislation is to prevent insolvency of schemes and
unaffordable annual membership contribution increases.
“Where there is an indication that schemes, and
administrators are violating any section of the Act and Regulation and that
information is presented to us, we investigate, inspect and issue instructions,
directives and rule on these matters,” said Dr Mini. The investigators have
been given four months to complete the probe.