Panel gets to heart of discrimination against black medical professionals

There needs to be diversification of people employed by medical scheme administrators who design policies and procedures to deal with fraud, waste and abuse (FWA) by medical practitioners.

This is one of the recommendations of a panel appointed by the Council for Medical Schemes (CMS) in a report investigating claims of racial discrimination by medical schemes against black practitioners.

The panel said there was unfair racial discrimination by the three biggest medical scheme administrators against black practitioners

It found that between 2012 and 2019 black practitioners were more likely to have been found to have committed fraud, waste and abuse (FWA) than their white counterparts by Discovery, Medscheme and Government Employees Medical Scheme (Gems).

FWA refers to claims that a provider is “not entitled” and common types include inflating claims, “card-farming” — where several individuals use a single member’s medical scheme card — billing code irregularities and claiming for non-claimable items.

The recommendation by the panel was meant to address the problem experienced by black practitioners, who found themselves unfairly discriminated against with the number of FWAs against them, compared with their white counterparts.

“There is a much greater chance of implicit bias entering a system if the creators of the system are homogeneous.

“Diversity, on the other hand, ensures that there is a diversity of life experiences created by historical structures of racism. This in turn will help identify the potential pitfalls of a system,” the panel of three advocates, Tembeka Ngcukaitobi SC, Kerry Williams and Adila Hassim, said in the interim report.

There is a much greater chance of implicit bias entering a system if the creators of the system are homogenous.

—  Report

The panel was mandated by CMS in 2019 to investigate two main issues.

The first was whether there was racial discrimination by schemes against black health-care providers. The second was whether black providers were being treated procedurally unfairly.

The investigation followed complaints by members of the Solutionist Thinkers and the National Health Care Professionals Association that they were being unfairly treated by medical aid schemes based on race and ethnicity.

The panel said to base its findings on a firmer ground than the complaints provided it appointed an independent expert, Dr Zaid Kimmie, skilled in mathematics, statistics and data analytics, to assess the outcomes of the FWA investigation processes by the three main administrators.

The panel said every scheme implicated denied there was unfair racial discrimination in their FWA investigation process.

The panel said the denial was based on FWA investigations being triggered by an automated system underpinned by an algorithm that flagged outlier practices for investigation. The schemes added that the denial was based on tip-offs and whistle-blowers.

The panel said it did not find evidence of explicit racial bias in the algorithms (to the extent that the workings of the algorithms were disclosed) and methods the administrators and schemes used to identify FWA.

“However, using the data that Discovery, Gems and Medscheme provided the panel and its expert, there is a substantial difference in FWA outcomes between black and non-black practitioners over the period January 2012 to June 2019.”

The panel said Gems, Medscheme and Discovery had failed to persuade it that the disproportionate effects that their risk management systems produce for black practitioners did not amount to unfair discrimination.

Across all schemes, black practitioners were 1.4 times more likely to be classified as having committed FWA than those identified as not black, it said.

“The probability that this distribution occurred by chance (that there is no correlation between racial status and FWA outcomes) is for all practical purposes zero,” the panel said, adding that the starkest differentials were found evident in a number of professional areas.

The panel said black general practitioners were 1.5 times more likely to be identified as FWA cases than their non-black counterparts and that black psychologists and black registered counsellors and social workers were three times more likely to be identified as FWA cases.

The panel said though each of the three schemes and administrators presented expert evidence to contest the findings of Kimmie, the panel found the disproportionate impact on black providers, which amounted to unfair racial discrimination, remained.

It also said despite some automation in the operation of the algorithms, there was always an element of human intervention at some point along the chain of investigation.

“In other words, the systems are not fully automated and therefore the FWA outcomes are not a product of only machines or their programmers.”

The panel said to avoid discrimination as a result of implicit bias, it was necessary to assume there was racial bias in the system, instead of assuming that systems were neutral.

It added that the CMS should issue more regular guidance on the issues which arise out of the FWA detection, investigation and sanction processes by the schemes and administrators.