Durban – Medical aid schemes have criticised the Health Professions Council of South Africa (HPCSA) for handing down fines of R20 000 and less to doctors found guilty of multiple counts of fraud.
A number of Durban doctors are among the healthcare professionals sanctioned by the council, none of whom was suspended from practising.
The sentiment from medical aid schemes which have fallen victim to fraudulent claims is that the doctors have escaped with slaps on the wrist, which will not act as a deterrent to others contemplating the same crime.
The Board of Healthcare Funders (BHF), which represents medical aid schemes, felt the council was “losing the war” on medical aid fraud.
The council regulates healthcare practitioners, but Elmarie Jensen, marketing manager of Genesis medical aid, argued it was failing to deal with doctors who defrauded schemes.
In June, the council found at least five Durban doctors guilty of fraud. One of the doctors faced 26 counts and was fined R70 000, with R50 000 suspended for five years, resulting in an effective fine of R20 000.
The doctor had charged a medical aid for services not rendered between 2012 and 2013, causing it financial prejudice.
Another doctor made four claims from medical aids for medication which was not dispensed.
The accounts or statements were incorrectly drafted, resulting in financial losses for the medical aid schemes.
The council fined him R40 000, with R20 000 suspended for three years.
A third doctor found guilty on three counts was fined R20 000, with R10 000 suspended for three years.
Two other doctors were fined a combined R100 000 for 13 counts, but R80 000 was suspended for five years.
“Wider consequences such as suspension from practising is one way that could scare would-be perpetrators from defrauding the schemes,” said Jensen.
“The problem with a fine as the only penalty or consequence is that it may not stop them. If they are caught and only have to pay a small penalty, why would they stop?”
She said irregular practices and fraud by medical practitioners amounted to billions of rand annually, and were a financial burden contributing to the overall cost of private healthcare in South Africa.
“All members of existing medical aid schemes foot this bill. We have experienced this type of fraud. A recent incident involved a Cape Town dentist. Our internal clinical auditors detected an unusual trend in claims from this dentist. He claimed about R120 000 for treating just four families during 2014/15. This was too suspicious coming from the same doctor in such a short period of time,” Jensen said.
Investigations revealed that the dentist had been claiming for teeth that had long been extracted; taken unnecessary x-rays; performed root canal treatment on non-existing teeth; and “a whole host of other irregularities”.
The dentist offered to repay the amount defrauded from the scheme, she said.
She was not sure if criminal charges were filed against the offending doctors.
Dr Elsabé Conradie, spokesperson for the Council for Medical Schemes (CMS), said medical schemes had mechanisms or investigation units to deal with criminal issues.
She said the council did not file criminal charges against perpetrators.
“The CMS does not regulate service providers, including doctors. It is the medical schemes that lay criminal charges against doctors. We regulate medical schemes and ensure that the members are protected. In other words, schemes have to govern the trust funds (member contributions) effectively and ethically according to the Medical Schemes Act,” she said.
Lamees Scholtz, the Board of Healthcare Funders’ (BHF) spokesperson, said the HPCSA was failing to curb this scourge against medical aid schemes.
“We are in discussions with them to involve all the other stakeholders to come up with working strategies. This type of crime is very difficult to investigate. Even if fraudsters get charged, these fines are definitely not a deterrent,” she said.
Dr Jonathan Broomberg, Discovery Health chief executive, said the levels of fraud in the medical aid industry remained at “concerning levels”.
“Discovery Health recovers more than R400m per annum in fraudulent claims of various types. It is important to note that only a small minority of health professionals and members commit fraud, and the vast majority are honest,” he said.
Questions on this issue were sent to the HPCSA on Thursday.
The council had promised to respond by Monday, but had not done so.