Black doctors up to 330% more likely to have claims flagged by medical aids

A newly-released interim report on allegations that some of the country’s biggest medical aid schemes have been racially profiling doctors, suggests that in some instances black practitioners are up to 330% more likely to be flagged for fraud, waste and abuse (FWA) than their white counterparts.

In 2019, the Council for Medical Schemes appointed a panel – headed up by advocate Tembeka Ngcukaitobi – to probe allegations that black practitioners’ were being treated unfairly.

The probe covered the period between January 2012 and June 2019 and focussed on three schemes in particular: Discovery, the Government Employees Medical Scheme (Gems) and Medscheme.

The interim report which was penned on the back of this probe, has now found there was indeed “unfair racial discrimination”.

“Over this period, across all disciplines and the aforementioned three schemes and administrators, black practitioners were 1.4 times more likely to be classified as having committed FWA than those identified as not black,” the report found – with the panellists having described the probability of this having occurred by chance as “for all practical purposes, zero”.

A clear “disproportionate impact on black providers”

There were, however, “clear differences in the scale of racial discrimination” between the schemes – with the panel’s expert’s finding that Discovery 35% was more likely to identify black providers as having committed FWA, Gems 80% more likely to do the same, and Medscheme a staggering 330% more likely to flag them.

During the investigation, the schemes all contested these figures. But the panellists found even on their own figures, there was “a disproportionate impact on black providers”.

“With regard to Medscheme, assuming the correctness of their expert’s methodology, it is 35% more likely to find black providers guilty of FWA. On GEMS own version, it is 47% more likely to find black providers guilty of FWA. [And] on Discovery’s version, it is 36% more likely to find black providers guilty of FWA,” they said.

In addition to finding that the black doctors were being unfairly discriminated against, the report also found some of the processes the schemes had adopted to “claw back” on disputed amounts owed to practitioners, were unfair.

“These findings are both serious and far-reaching. But we believe that it is important to stress that we have not found evidence of deliberate unfair treatment – the evidence shows the unfair discrimination is in the outcomes,” the panellists said.

Attempts to block release of report

The report was made public on Tuesday afternoon, after the North Gauteng High Court threw out an urgent bid from Gems and the Board of Healthcare Funders to interdict its release earlier in the day.

On Sunday – just hours before it was originally due to be made public – Gems and the board rushed to court, where they argued the report contained “scathing” findings and allegations and that Gems, in particular, had not been given an opportunity to respond thereto.

Judge Colleen Collis found the case was not urgent – questioning why Gems and the board had waited until the last minute to approach the court – and struck it from the roll.

Gems’ was, however, adamant it had never intended to “block” the release of the report, “But to request that due processes be followed in ensuring that affected parties had a view of the report before it was released to the public,” it said.

The schemes respond:

Of the report itself, the scheme’s principal officer, Dr Stanley Moloabi, said he had “noted with concern” the findings.

“The panel has afforded impacted schemes a period of six weeks to study the report and thereafter provide formal comments based on the interim findings,” he said. “Gems will take this opportunity to closely study the full report findings, and the recommendations of the panel to establish a way forward.”

Moloabi said the scheme had a “zero-tolerance” stance on all forms of discrimination and pledged to implement corrective action where it was recommended.

Discovery, meanwhile, said it had not had sufficient time and access to be able to analyse the report yet and would also comment further in the coming weeks.

In the meantime, the scheme said while it did not accept any racial discrimination in its processes, it did “accept and respect” the panel’s recommendations and would “endeavour to work hard within the healthcare system to ensure that going forward, outcomes are more satisfactory, balanced and representative”.

“Promoting a diverse health profession that reflects the demographic profile of South Africa is fundamental to a sustainable and fair healthcare sector. [Discovery is] committed to transformation in the healthcare sector and we are acutely aware of the complex challenges faced by healthcare professionals,” it said.

Medscheme also “categorically rejected claims that it performs any form of racial profiling when assessing or auditting healthcare claims”.

“[And] we are extremely disappointed that we were not afforded an opportunity to review the interim report of the panel before it was published publicly, as had been agreed,” the scheme’s executive director, Dr Lungi Nyathi, said.

Nyathi said the scheme would now be reviewing the report and that it, too, would be making a formal submission in the coming weeks in response thereto.

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