Medical aids act like prosecutors, inquiry told
Some medical aids act like prosecutors and judges when investigating doctors for potential fraud – especially black doctors, the Council for Medical Schemes heard yesterday, according to Times Select.
The medical aid regulator is holding hearings into claims that administrators racially profile ‘fraudulent’ doctors.
The National Healthcare Professionals Association (NHCPA) has accused medical aids and medical aid administrators Discovery and Medscheme of behaving unlawfully. NHCPA head Donald Gumede told a panel of three advocates about a dermatologist, referred to only as Dr Singh, who was informed in 2017 he removed too many moles and lesions from patients, compared to other skin doctors. This was despite his having 28 years’ experience and three practices, and providing photographic evidence that the patients required treatment.
‘This (story) demonstrates the general modus operandi. They have effectively become prosecutors and judges in their own cases,’ Gumede is quoted as saying.
Medscheme asked Singh for proof of equipment and his qualifications, which NHCPA lawyer Nqabayethu Buthelezi said had nothing to do with his billing or his patients.
Singh was eventually blacklisted and, despite recently winning an appeal against Medscheme at the Council for Medical Schemes in June, remains blacklisted.
This means all patients of medical aids administered by Medscheme (Bonitas) must pay him directly.
Medical aid schemes have become a law unto themselves with untold power to determine which private doctor practices in the country should close shop.
This, according to The Star, was the scathing submission of the president of Health Professions Council of SA (HPCSA) Dr Kgosietsile Latlape. Doctors have suffered gross abuse of power at the hands of the schemes who launched illegal fraud investigations when they wanted their money, he claimed.
The schemes took advantage of the fact that there was no legislation compelling them to pay private doctors, nor were there agreed tariffs in the sector, said Letlape.
The so-called designated service providers, which was a group of practices preferred by medical aids, were flourishing to the detriment of many practices.
‘Now, being paid depends on the mood of the administrator. You have no legal right to be paid by the funder, irrespective of how you behave or what you do,’ added Letlape.
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