A Durban-based private hospital group is in a legal war with 13 medical aid schemes that it claims are refusing to pay R27m it is owed for hundreds of ‘pre-authorised’ hospital visits, which, if not resolved could result in patients being sued for the money, notes a Business Day report.

City Hospital (Pty) Ltd – which owns City Hospital and Ascot Park Hospital – claims that administrator Medscheme is behind the payment ban because it raised ‘anomalies’ in admission patterns at the two hospitals. It says Medscheme claims certain directors of the group, who are doctors, are enriching themselves through admissions.

The two biggest debtors are Bonitas, which owes R14.5m, and Polmed, which owes just under R10m.

The hospital group says it is being financially crippled by the non-payment and wants a court to direct that the registrar and the Council for Medical Schemes (CMS) undertake an urgent inquiry. It wants CMS to declare the conduct of medical aid schemes as an ‘undesirable business practice’ and to probe who at Medscheme had motivated for the medical aids to withhold payment and ‘to what extent is the type of behaviour is prevalent against others and who they are’.

In an affidavit filed with the KZN High Court (Durban), CMS CEO Dr Sipho Kabane pointed out the complaints process is governed by legislation. ‘It is inappropriate for the applicant to seek that this court direct how I should conduct an investigation,’ he is quoted as saying by Business Day.

Paul Midlane, GM of healthcare forensics for Medscheme, said an audit had revealed that doctors with the highest admission rates were also shareholders in the group. ‘While it is not unlawful, admitting doctors have an ethical duty to notify patients of this potential conflict of interest.’ He said the majority of patients were admitted directly into the hospital without screening.

‘It is clear from our data that doctors are admitting the vast majority of patients and then only consulting for the first time – practically speaking the hospitals are being used as waiting rooms.’ Midlane said pre-authorisations were issued in good faith and were not a guarantee of payment.

‘In the past two years, Medscheme has paid the hospitals R323m and we believe a substantial portion of that could have been avoided if it wasn’t for unnecessary admissions.’

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