Following the release of the Council for Medical Schemes’ (CMS) Section 59 Investigation Preliminary Report, Dr Katlego Mothudi, Managing Director of the Board of Healthcare Funders (BHF) said, “The BHF recognises the negative impact that the issues raised by the panel can have on the healthcare industry, and equally recognises the impact of fraud and corruption on the healthcare sector; and thus welcomed the processes undertaken by the CMS as we are of the view that these processes seek to ensure that stakeholders are aligned in purpose and do not engage in activities that may undermine the democratic processes that seek to support any interventions that prioritise and put the welfare and health of citizens first.”
The Section 59 Investigation probed allegations made by healthcare practitioners that they are being discriminated against by medical schemes and administrators; and their claims are being withheld based on their race and ethnicity.
The Board of Healthcare Funders (BHF) wishes to clarify that the decision taken by the representative body and its member, the Government Employees Medical Scheme (GEMS), to interdict the release of the Section 59 Investigation Preliminary Report (Preliminary Report) was triggered by a gap in procedural processes followed by the release of the Preliminary Report. The interdict was an effort to ensure that due process is followed in relation to the investigations by the independent panel constituted to investigate allegations of racial profiling in relation to fraud, waste and abuse investigations (Panel) as well as the issue of the Preliminary Report by the independent panel.
The BHF as the healthcare funding industry's representative body, recognises that the Panel must fulfil its obligations as outlined in its approved Terms of Reference. The Panel did not, however, implement the approved Terms of Reference nor the subsequent processes that it initially indicated would be followed.
The BHF supports openness and transparency and the principles of natural justice that dictate that parties should be made aware of the findings made against them by an administrative body such as the Panel and be presented with a reasonable opportunity to correct any errors or inaccuracies set out in any findings made by such administrative body prior to the publication of a report to the general public. This serves to ensure that unnecessary adverse inferences are drawn in relation to named parties to their detriment.
Mothudi conceded that the private healthcare industry is grappling with a high prevalence of fraud and corruption, which is exacerbated by lack of visible policing, gaps in monitoring systems, inappropriate consequence management processes, long-standing malpractices that have become entrenched as well as low levels of information sharing within the industry.
Dr Mothudi points out that several efforts are being made in the medical scheme industry to root out fraud, waste and corruption. In efforts to do so, BHF member schemes follow various processes to determine trends and anomalies in claims and use these to determine the outcome of claims.
“We are of the view that our members have and had no agenda to intentionally discriminate any of the medical professionals, as we have a zero-tolerance to any forms of discrimination,” he said.
The BHF, together with impacted members, will closely review the full report and engage with the Panel and the CMS to establish a way forward and establish remedial interventions where such interventions are required.
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