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.
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.
This article was republished from Moneyweb with permission