Latest news with #Medscheme
IOL News
3 days ago
- Health
- IOL News
Medical schemes under fire for bias against black professionals
A section 59 report revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work. Image: File There must be consequences and punitive measures, which include back payments by medical schemes, that were found to have applied systemic discrimination against black health professionals when they applied risk ratios against them. This call has come after the findings of a Section 59 investigation report revealed that three medical schemes, namely GEMS, Medscheme, and Discovery, applied discriminatory risk ratios to black health professionals, in disciplines such as physiotherapy, psychology, and social work, who are 'more likely' to be guilty of fraud, waste, and abuse. It is unclear how many medical professionals were affected by racial profiling and how many lost their business practices. The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. 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The findings of the report raised questions during the meeting about equity within the profession, igniting discussions about fairness, accountability, and restitution. Health Minister Aaron Motsoaledi addressed the Portfolio Committee on Health regarding the Section 59 investigation report, which revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work. Image: GCIS Motsoaledi said the Act does not indicate what steps should be taken, and currently, it appears the medical schemes decide their measures. 'This is a statutory matter due to the silence in the Act. It does not indicate the steps that the schemes must take when they investigate such a fraud. That is the weakness picked up by the panel, and the Act itself does not provide guidance on what should be done. 'The medical schemes have decided to divulge their methods, which were unfortunately tampered with by racial bias. Even if the Act does not outline what must be done, whatever is done in a new South Africa governed by democracy cannot be informed by racial profiling. We will have to look into that,' said Motsoaledi. The minister said the members of Parliament are 'not mere bystanders and observers', and have an onus on them to have the Act amended to speak specifically to such reform. Motsoaledi said they are still studying the report, and legal advice is being sought after its release on Monday. Chairperson for the Council for Medical Schemes (CMS), Dr Thandi Mabeba, said the council will have a special sitting next Monday to interrogate the findings, recommendations, and the implications of such recommendations. Dr Mabeba said they would also hold engagements across the industry, including the steering committee. 'The minister has alluded to the report, which has damning findings, and as such, we need to apply our minds in ensuring that we guide the industry in a manner that is legally and in line with our statutory mandate.' On Monday, chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, welcomed the findings of the Section 59 investigation panel. 'The report paints a concerning picture of the disproportionate impact that medical schemes' fraud, waste, and abuse systems have had on black healthcare providers…These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste, and abuse systems. 'It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve. 'We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,' said Dr Dhlomo. Get your news on the go, click here to join the Cape Argus News WhatsApp channel. Cape Argus
IOL News
3 days ago
- Health
- IOL News
Medical schemes face scrutiny over racial discrimination against black health professionals
Health Minister Aaron Motsoaledi addressed the Portfolio Committee on Health regarding the Section 59 investigation report, which revealed that three medical schemes applied discriminatory risk ratios to black health professionals in disciplines such as physiotherapy, psychology, and social work. Image: GCIS There must be consequences and punitive measures, which include back payments by medical schemes, that were found to have applied systemic discrimination against black health professionals when they applied risk ratios against them. This call has come after the findings of a Section 59 investigation report revealed that three medical schemes, namely GEMS, Medscheme, and Discovery, applied discriminatory risk ratios to black health professionals, in disciplines such as physiotherapy, psychology, and social work, who are 'more likely' to be guilty of fraud, waste, and abuse. It is unclear how many medical professionals were affected by racial profiling and how many lost their business practices. The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Next Stay Close ✕ However, in the absence of remuneration guidelines by the National Health Act, Health Minister Aaron Motsoaledi, during a portfolio committee meeting on Friday, said they will seek legal advice on the matter. The findings of the report raised questions during the meeting about equity within the profession, igniting discussions about fairness, accountability, and restitution. Motsoaledi said the Act does not indicate what steps should be taken, and currently, it appears the medical schemes decide their measures. 'This is a statutory matter due to the silence in the Act. It does not indicate the steps that the schemes must take when they investigate such a fraud. That is the weakness picked up by the panel, and the Act itself does not provide guidance on what should be done. 'The medical schemes have decided to divulge their methods, which were unfortunately tampered with by racial bias. Even if the Act does not outline what must be done, whatever is done in a new South Africa governed by democracy cannot be informed by racial profiling. We will have to look into that,' said Motsoaledi. The minister said the members of Parliament are 'not mere bystanders and observers', and have an onus on them to have the Act amended to speak specifically to such reform. Motsoaledi said they are still studying the report, and legal advice is being sought after its release on Monday. Chairperson for the Council for Medical Schemes (CMS), Dr Thandi Mabeba, said the council will have a special sitting next Monday to interrogate the findings, recommendations, and the implications of such recommendations. Dr Mabeba said they would also hold engagements across the industry, including the steering committee. 'The minister has alluded to the report, which has damning findings, and as such, we need to apply our minds in ensuring that we guide the industry in a manner that is legally and in line with our statutory mandate.' On Monday, chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, welcomed the findings of the Section 59 investigation panel. 'The report paints a concerning picture of the disproportionate impact that medical schemes' fraud, waste, and abuse systems have had on black healthcare providers…These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste, and abuse systems. 'It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve. 'We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,' said Dr Dhlomo.
Zawya
6 days ago
- Health
- Zawya
Committee on Health Welcomes Findings of Section 59 Investigation Panel
The Chairperson of the Portfolio Committee on Health, Dr Sibongiseni Dhlomo, has welcomed the findings of the Section 59 investigation panel, which has uncovered systemic racial discrimination in the implementation of fraud, waste and abuse systems by medical schemes and administrators. 'The report paints a concerning picture of the disproportionate impact that medical schemes' fraud, waste and abuse systems have had on black healthcare providers,' said Dr Dhlomo. 'The statistical evidence presented by the panel's expert, clearly demonstrates that black providers were significantly more likely to be found guilty of fraud, waste and abuse compared to their non-black counterparts.' The panel's analysis revealed that across the three major schemes investigated – Discovery, GEMS and Medscheme – black providers were between 1.5 to 3.5 times more likely to be identified as guilty of fraud, waste and abuse. In certain disciplines, such as physiotherapy, psychology and social work, the risk ratios for black providers were even higher, reaching up to 12 times more likely to be found guilty. 'These findings are deeply troubling and point to systemic flaws in the design and implementation of the fraud, waste and abuse systems,' continued Dr Dhlomo. 'It is unacceptable that black healthcare providers have been subjected to such blatantly discriminatory treatment, which has undoubtedly had a devastating impact on their livelihoods and the communities they serve,' he said. The committee commends the panel for its thorough and independent investigation, and welcomes the recommendations made to the Council for Medical Schemes (CMS) to ensure the ongoing monitoring of the fraud, waste and abuse systems to prevent further discriminatory outcomes. Dr Dhlomo stated that he is in discussions with the Minister of Health, Dr Aaron Motsoaledi, about the report. The aim is to ensure that the Minister, the Department of Health, and the entities that the committee oversees and that have been implicated will be invited to provide a briefing to the committee on the findings, outcomes and recommendations presented in the report. 'We cannot allow such systemic discrimination to continue unchecked, as it undermines the transformation of the healthcare sector and the constitutional right to equality,' said Dr Dhlomo. Distributed by APO Group on behalf of Republic of South Africa: The Parliament.
Daily Maverick
07-07-2025
- Health
- Daily Maverick
Probe finds evidence of racial discrimination against black healthcare providers by medical schemes
The section 59 panel investigating allegations of racial discrimination against black healthcare providers by medical schemes in South Africa issued its final report on Monday, 7 July. The section 59 panel's final report, handed to Minister of Health Aaron Motsoaledi on Monday, found that between 2012 and 2019 there was evidence that the fraud, waste and abuse (FWA) systems used by medical schemes showed racial discrimination against black service providers. The investigative panel, commissioned by the Council for Medical Schemes (CMS) and chaired by advocate Tembeka Ngcukaitobi, began looking into the matter in 2019 after healthcare providers, represented by two associations, made public allegations about their treatment by medical schemes and administrators. 'We were not a court of law… We did not have to make legal findings applying the Promotion of Equality and Prevention of Unfair Discrimination Act or applying section 9 of the Constitution, but what we did have the power to do was to make findings of fact, and that… simply leads to one conclusion. The evidence of the risk ratios before us showed racial discrimination against black service providers by the [medical] schemes,' said Ngcukaitobi at a press briefing marking the handover of the report on Monday. According to the CMS, the inquiry focused on two issues: whether there was racial discrimination by medical schemes against black healthcare providers; and procedural fairness in the treatment of black healthcare service providers. Racial discrimination The panel developed a tool to measure the performance of medical schemes' fraud, waste and abuse systems, looking at discriminatory outcomes or unequal treatment for healthcare providers. 'This risk ratio is basically a tool that we developed to work out the likelihood that a black practitioner would be subjected to an investigation, a finding and a penalty, versus a white practitioner,' said Ngcukaitobi, adding that the panel looked at risk ratios across different medical disciplines and years, between 2012 and 2019. The findings included: In 2014, black dental therapists under the GEMS medical scheme were about three times more likely to be investigated and found guilty of fraud, waste and abuse than white dental therapists; In 2017, black psychiatrists under Discovery were about 3.5 times more likely to be investigated and found guilty of fraud, waste and abuse than white psychiatrists; and In 2018, black anaesthetists under Medscheme were about 6.5 times more likely to be investigated and found guilty of fraud, waste and abuse than white anaesthetists. Ngcukaitobi said there was scope to improve the methodology used by the panel to determine the probable risk ratios for different years and disciplines. 'We have explained that the tool… should be continuously improved, but it is useful as a starting point. We have also recommended an annual assessment of the impact of FWA [systems] on black providers… [and] recommended the splitting of specific disciplines in order to monitor the instances of FWA among the healthcare providers,' he said. Procedural fairness The panel released an interim report in 2021, with findings of unfair discrimination on the basis of race. Subsequent to its release, various stakeholders – including medical schemes – had the opportunity to make further submissions to the panel in 2021 and 2023, according to Dr Thandi Mabeba, chairperson of the CMS. '[In the interim report], what we had found in relation to procedural fairness was that the FWA procedures for the recovery of monies allegedly owed is unfair and it violates the rights to procedural fairness of individual practitioners. We found that the schemes should make changes to the manner in which they claw back monies that they claim practitioners owe to them,' said Ngcukaitobi. 'We've received further submissions, but we remain unpersuaded that our interim findings were incorrect. Accordingly, we confirm the findings and recommendations in the interim report that the procedure that is followed by medical schemes, when they claw back money allegedly owed by practitioners or where they investigate instances of fraud, waste and abuse, are unfair.' Ngcukaitobi noted that part of the problem was that the Medical Schemes Act didn't contain procedures for the administration of fraud, waste and abuse systems, leaving it up to individual medical schemes to make decisions about how to investigate possible infractions and impose penalties. 'The legislation is lacking. It has several gaps. It's not keeping up with technology… We say that the CMS, as the regulator responsible for the implementation of the fraud, waste and abuse systems, is required to ensure that schemes and administrators act procedurally fairly. It is within the CMS's discretion as to how it chooses to progress this object with various stakeholders,' he said. Among the recommendations made by the panel to improve procedural fairness in medical schemes' fraud, waste and abuse systems were: Developing an early warning system that allowed medical schemes to notify service providers as soon as schemes became aware of any circumstances which might lead to the application of section 59, subsection 3 of the Medical Schemes Act; Reviewing the 'audit and clawback time period' for medical aid schemes, as there were instances where healthcare providers were called upon to pay back money to schemes years after alleged infractions; Ensuring a mechanism to assist healthcare providers with representation when accused of fraudulent, wasteful or abusive conduct by medical schemes, to prevent isolation or coercion of accused persons; and Providing complete transparency regarding the software, algorithms and artificial intelligence programmes used by medical schemes to monitor claims made by providers and members alike. 'Most of the evidence we had was that there is a software programme that the schemes use to detect fraud, waste and abuse, but there's no transparency in relation to the input into that software programme… and because it's an invisible programme, it's impossible to work out whether it's discriminatory or not in relation to its outcomes,' said Ngcukaitobi. 'If the schemes persist with the argument that they will not allow this transparency because it will undermine the detection of fraud, waste and abuse, then we say the Council for Medical Schemes must introduce a mechanism where… the council itself has full transparency relating to the software, algorithms and artificial intelligence programmes that the schemes use. The schemes ought to be accountable to a public body for the systems they use, as this in turn ensures accountability to the public, whilst maintaining a form of confidentiality.' Upon receiving the section 59 investigation panel's report, Motsoaledi said that the National Department of Health would study the findings before issuing an official statement. BHF rejects findings The Board of Healthcare Funders (BHF), a nonprofit company representing medical schemes and administrators, released a statement rejecting the panel's findings on Monday. 'We still need to study the final report. However, we are disappointed that the section 59 inquiry panel has confirmed that it has upheld the findings made in the interim report released in 2021. We believe these findings are demonstrably and fundamentally flawed and, if allowed to stand, will open the door for runaway fraud and corruption in the healthcare sector,' it said. The board said fraudulent claims, overservicing, abuse of benefits and improper billing practices cost South Africa's medical schemes about R30-billion each year. 'Based on comments made by the section 59 inquiry panel in today's media briefing, the BHF believes that the final report continues to be underpinned by serious methodological and interpretive flaws, all of which we raised following the release of the interim report in 2021,' it said. The issues the BHF raised with the panel's methodology included: Unscientific methods to assign race, using surnames to categorise providers; Failing to account for exposure bias, which occurs when a group is more likely to be involved in a process or activity simply because of greater contact or interaction; and Confusing correlation with causation, by assuming discrimination without 'rigorously considering other relevant variables such as provider billing patterns, patient load, or socioeconomic contexts'. 'Taken together, these cumulative weaknesses undermine the central finding that black providers were nearly twice as likely to be investigated,' it said. According to the BHF, both the board and its members had undertaken 'significant reforms to strengthen fairness, transparency and accountability', including a comprehensive review of fraud, waste and abuse protocols. 'The BHF remains committed to working collaboratively with the CMS, regulators and the healthcare community to strengthen South Africa's healthcare funding system. While we reject the findings of the section 59 investigation as flawed, we remain steadfast in our pursuit of a healthcare system grounded in integrity, justice and sustainability,' said Dr Katlego Mothudi, managing director of the BHF. DM
IOL News
07-07-2025
- Health
- IOL News
Probe finds evidence of racial bias against black healthcare providers by South Africa's medical schemes
Health Minister Dr Aaron Motsoaledi has received the long-awaited report which confirmed allegations of racial discrimination and unfair practices by some of South Africa's leading medical schemes against Black healthcare practitioners. Image: Oupa Mokoena / Independent Newspapers The Board of Healthcare Funders (BHF) has firmly rejected the long-awaited Section 59 report, which on Monday found positive and glaring alleged racial bias and discrimination by medical health schemes against black health professionals. Presented by panel chair Advocate Tembeka Ngcukaitobi, the report found systemic procedural unfairness and a deeply entrenched power imbalance that over the years has disproportionately and negatively impacted black medical professionals. The inquiry commissioned by the Council for Medical Schemes (CMS), launched in 2019, scrutinised practices by medical aid schemes such as Discovery, Medscheme and the Government Employees Medical Scheme (GEMS) between 2012 and 2019. "We confirm the findings and recommendations in the interim report, that the procedure followed by medical schemes when they claw back monies allegedly owed by practitioners or when they investigate instances of fraud, waste, and abuse is unfair," said Ngcukaitobi. On Monday, Minister of Health Dr. Aaron Motsoaledi, made the report public after receiving the investigation report on the findings of the inquiry conducted by the Section 59 Investigation Panel into allegations of racial discrimination by medical schemes. The inquiry was launched after doctors and other practitioners accused medical aid administrators of unfairly targeting them with audits, delaying payments or terminating contracts without clear justification. This comes after some black healthcare providers and members of Solutionist Thinkers and the NHCPA (National Health Care Professionals Association), in 2019, made allegations that they were being treated unfairly by schemes and administrators, based on race and ethnicity. The written submissions alleged that the schemes were intimidating and bullying providers through the implementation of their FWA systems (used by schemes and administrators to detect, investigate and determine providers), including by refusing to reimburse providers directly and coercing them into agreeing to acknowledgment of debt (AODs). The schemes were alleged to be treating providers unfairly and in particular were alleged to be targeting black providers. The NHCPA explained that it had anecdotal evidence that the schemes' forensic audit process was more prevalent among black providers and pointed out that the panel could obtain empirical information through its investigation. The report's statistical risk ratios developed during the investigation found that black practitioners were significantly more likely to be flagged, investigated, and penalised compared to their white counterparts. It found that in 2014 at GEMS black dental therapists were up to 3 times more likely to be flagged, while for Discovery in 2017, the report found that black psychiatrists were 3.5 times more likely. For Medscheme in 2018, the report suggests that black anesthetists were 6.5 times more likely to be found guilty of fraud, waste, and abuse (FWA). "Let me repeat this, we were not a court, we did not adjudicate individual complaints, we did not run a trial and make findings about unfair discrimination in terms of Section 9 or the Pepuda Act, we only considered the facts and the facts lead us to one conclusion that the evidence of the risk ratios before us showed racial discrimination to black service providers by the schemes. "These risk ratios are not scientific certainties, but they are highly probable indicators of discrimination," Ngcukaitobi added. While still studying the report, the BHF, a nonprofit company representing medical schemes and administrators, said it firmly rejects the findings of the final Section 59 investigation. "We still need to study the final report; however, we are disappointed that the Section 59 Inquiry panel has confirmed that it has upheld the findings made in the interim report released in 2021. We believe these findings are demonstrably and fundamentally flawed and, if allowed to stand, will open the door for runaway fraud and corruption in the healthcare sector," it said. On alleged fraudulent claims, the BHF stated: "Fraudulent claims, over-servicing, abuse of benefits, and improper billing practices cost South Africa's medical schemes around R30 billion each year. These losses directly impact the contributions and benefits of 9.7 million scheme members, the majority of whom come from historically disadvantaged communities. Fraud, waste, and abuse (FWA) inflate healthcare costs, reduce member benefits, and drive up premiums, placing disproportionate financial strain on working-class families." The issues the BHF raised with the panel's methodology included: Unscientific methods to assign race, using surnames to categorise providers; Failing to account for exposure bias, which occurs when a group is more likely to be involved in a process or activity simply because of greater contact or interaction; and Confusing correlation with causation, by assuming discrimination without 'rigorously considering other relevant variables such as provider billing patterns, patient load, or socioeconomic contexts'.
