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Medical claims ‘a significant future risk’

Published Nov 9, 2023


The Auditor-General has identified skyrocketing medical claims as an emerging risk that posed a future problem for health departments.

The departments have paid R1.42 billion in medical claims in 2022-23 and current claims stand at R68.01 billion.

Briefing the Standing Committee on Public Accounts (Scopa), business executive at the A-G’s Office, Andries Sekgetho, said they had conducted audits and identified pressure points to spur government institutions to focus on elements that went wrong in their sectors.

“We identified an emerging risk and possible problem for the sector in that continuation of payment of these medico-legal claims could pose a significant future problem.

“Money that is being expended could be spent elsewhere and implement delivery of services,” Sekgetho said.

In 2015, the health department identified key initiatives to deal with medical claims and made resolutions on areas that included litigation strategy and managing medical records.

The national department had decided to acquire a management case system to roll out in provinces to assist with medical claims records.

The system, which was to be rolled out to eight provinces by March 2020, is partially used only in the Free State.

A total of R1.6 million of the R3.6 million was paid to the service provider for the services.

“The non-adherence in the way it is implemented to the utilisation means that currently (departments) use manual documents and manual processes that have their own limitations and challenges.

“That begs the question with the quality of decision-making by the management in the absence of proper supporting evidence and it also affects when you have to defend those cases,” Sekgetho said.

He also said their audit has found a lack of dedicated staff or co-ordinating structures to oversee management of patient safety and patient complaints.

There was also inadequate human resource capacity and lack of medical expertise to manage the medical claims case load and a shortage among administrative staff members, among other issues.

Sekgetho painted a bleak picture of the impact of medical claims on the department’s budgeting process.

The A-G’s office said money that should be used for service delivery was used to pay medico-legal claims.

“The budget set aside for medi colegal claims could be used for service delivery and the other provinces utilise money shifted from goods and services to pay for the claims,” it said in its report.

Total medical claims against the departments were currently standing at R68,01 billion, excluding Limpopo, as its audit was not signed off at the cut-off date.

MPs heard that the health departments have committed invoices amounting to R17.8 billion for medical claims in the 2023-24 financial year.

The department had paid R1.4 billion towards the claims as at the end of March 2023.

DA MP Alf Lees said the emphasis has been on administration and documentation, which were in a mess.

“The fact is they have a massive number of claims based on poor healthcare and, therefore, if one wants to reduce the claims, the key must be fixing the poor healthcare,” Lees said.

ANC MP Sakhumzi Somyo said the diminishing revenue and a look into liabilities should be a cause for alarm.

Somyo noted with concern that the national department devised the case management system, but it was not being used.

“It becomes a bigger problem. Those looking for solutions are distant from areas which experience these kinds of challenges,” he said.

Scopa chairperson Mkhuleko Hlengwa said the professional conduct of health practitioners and consequence management for negligence and escalation in medical claims bills were worrisome.

“I don’t see it reducing anytime soon if multi-pronged interventions are devised in ensuring there is no sem-blance of coherence in the ecosystem in so far as management of this issue is concerned,” he said.

Hlengwa said the high medical claims posed a risk to the fiscus and service delivery.

“I lament the collapse of the State Information Technology Agency that is supposed to be in the forefront to assist government departments and entities to manage issues,” Hlengwa added.

Cape Times