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Medical aids 'spy on doctors'

Court told schemes also 'killing practices' by penalising them for fraud without proof


Doctors have accused South Africa's biggest medical-aid schemes of spying on them and sneaking hidden cameras into their consulting rooms.
The healthcare practitioners also claim the schemes are guilty of withholding payment from doctors without proof of misconduct.
These startling claims are contained in documents filed in the High Court in Pretoria last week by the National Healthcare Professionals Association, in a claim against 19 medical-aid schemes. The association was formed in October last year and has 320 members nationally. Of these, 65 are part of the court application.The association claims in its court papers that medical-aid schemes are deliberately withholding money from doctors - or demanding that practitioners refund money already paid to them - over a "suspicion" that wrongdoing had taken place, even when the allegations were denied.
These claims can involve matters dating from as long as four years before.
In a case in February this year, Discovery Health demanded R1.1-million from the practice of Dr Edwin Thabo Mabuza, from Burgersfort in Limpopo, for "invalidated claims", the papers show.
'Completely bullied'
The association claims that section 59 of the Medical Schemes Act allows schemes to recover money only when theft, fraud, negligence or misconduct has actually been proven - but that this is not happening.
It has asked the court to make a declaratory order that the act does not permit medical aids to withhold payment without proving their allegations.
Several of the doctors involved in the lawsuit told the Sunday Times this week that they were at their wits' end.
Dr Mangana Makhumisane from Vosloorus, Gauteng, said Medscheme told him last October he owed R11,035 for using a code incorrectly.But Professor Alex van den Heever, chairman of social security systems administration and management studies at the University of the Witwatersrand's graduate school of public and development management, said medical schemes were justified in attempting to detect and address fraud by doctors.
"They have large databases, which allow them to detect unusual conduct. In many instances this will be more than a 'mere suspicion', while nevertheless falling short of the evidentiary bar for a conviction," he said.
Medscheme, which is an administrator for about a dozen of the respondents including Bonitas, said it had been notified of the case.
"Medical-scheme claims are paid upon presentation and in good faith," said Medscheme general manager for healthcare forensics Paul Midlane. "Claiming patterns and behaviour are only properly reviewed and validated retrospectively."
Strictest standards
Midlane, who stressed he was commenting on behalf of Medscheme, not its clients, added: "When billing irregularities are identified, the provider is always given an opportunity to respond."
Discovery Health CEO Jonathan Broomberg said: "Only a small minority of the over 20000 health professionals commit fraud and billing abuse and we have a responsibility to deal with this actively."
He said investigations "adhere to the very strictest standards".
Dr Gunvant Goolab, the principal officer of the Government Employees Medical Scheme, said schemes had to protect themselves.
Jeremy Yatt, principal officer of Fedhealth, said "irregular or over-claiming is costing the industry millions of rands every year and is on the increase".
steenkampT@sundaytimes.co.za, savidesM@tisoblackstar.co.za..

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