Durban - The family of a Northern KwaZulu-Natal woman who collapsed and died are seeking legal advice about pursuing a civil claim against a medical aid scheme for allegedly suspending payments for her dialysis treatment.
The 53-year-old died earlier this month after missing four dialysis sessions. She had been on dialysis for two years.
Discovery Health had apparently stopped paying her dialysis practitioner, who is based in Mtubatuba.
It had suggested going to another centre in Richards Bay for treatment, but the family apparently refused, saying it was too far away from their home.
The doctor, who did not want to be named, said she had regularly informed the woman about paying cash, because Discovery was the second medical aid scheme to suspend payments to her practice after conducting audits.
She believed these clinical audits were not random, but part of racial profiling medical aids were accused of.
She said in April, Discovery had stopped making payments to members she was treating, and she was asked for these members’ confidential clinical files and blood samples.
After getting patients’ consent, she forwarded the information to Discovery.
“I sent three out of the six files I had. They said I had given them incomplete information and wanted me to come to their offices. I told them I don’t have the money to as I also hadn’t been paid since February by Medscheme medical aid. I asked that we reschedule,” she said.
She was running out of consumables, equipment and other items used to perform dialysis and had to borrow from other facilities. At some point she also treated patients pro bono.
“When the patients returned to me, Discovery told me it would move them to other facilities and it was going to claim back the money it had paid to me,” she said.
On June 3 she was still treating patients, including the woman that died. With her consumables running low, the next day she sent a text to her patients asking if they could pay in cash.
Dialysis sessions cost about R2 000 per session – up to R6 000 a week for some patients.
She said on June 5, the woman did not come for treatment and the next day the doctor had a conference call with the medical aid and the woman’s son, who wanted to know why the doctor could no longer treat his mother.
“(Discovery) told him to take his mother to a facility in Richards Bay, which is more than an hour’s drive for the family. They said I should phone back alone. On the Friday the woman stayed home and did not get treatment. On that day the family contacted the medical aid, telling them the woman was getting worse,” she said.
She, too, contacted Discovery, asking it to intervene. Discovery apparently asked her to resume treating patients, saying it would find another way of conducting its audit.
“I asked for this to be sent to me via email, but little did I know the patient had already died by then.”
With 10 days left for the public to make submissions on the Section 59 investigation into allegations of racial profiling against black doctors by medical aids schemes, Discovery Health and Medscheme have denied racial profiling.
Thembeka Ngcukaitobi, left, with Dali Mpofu. Ngcukaitobi will head an investigation into allegations of racial profiling against Black, Coloured and Indian private medical practitioners, the Council for Medical Schemes has said. Picture: Brenda Masilela/ANA
Discovery Health said that had the Mtubatuba doctor attended the meeting they wanted to have with her, the patient’s death could have been avoided.
Discovery CEO Dr Jonathan Broomberg said their probe began in April.
“We only suspended payment after extremely serious concerns were confirmed. We didn’t suspend business with the practice; we withheld payment for a period until these concerns could be addressed with the practice,” he said.
Broomberg said they found that some of the doctor’s nurses were not registered and that she was also not always present, leaving unqualified nurses to conduct the dialysis.
The doctor denied this, saying she was always at her practice and her nurses were registered.
“I opened this centre to help people because of a lack of dialysis centres in this part of KZN. I didn’t open it for money. I process all the claims and handle my own admin so that I can be accountable,” she said.
Medscheme CEO Anthony Pedersen said Medscheme used a predictive analytics system to identify high-scoring providers based on their claiming behaviour in comparison to their peers.
“Medscheme solely relies on the practice number for identification of a healthcare provider’s practice,” he said.
He said Medscheme paid approximately 24 500 providers monthly.
In 2018, it investigated 1 101 cases, of which 830 had forensic findings.
“We opened 19 criminal cases in 2018. We reported 94 providers to the Health Professions Council of South Africa for unethical conduct,” he said.
Has Discovery flouted the law?
Medisyn Clinical Consulting medical law consultant Shafrudeen Amod said medical aids did not have a mandate to monitor the qualifications and supervision of healthcare providers, or patient safety.
“If there are concerns about this, it must be urgently communicated to the HPCSA (National Health Care Professionals Association) or the police. This is purely about perceived fraud,” he said.
Amod said he felt Discovery had flouted the Medical Schemes Act and the National Health Act in this case, and he felt that Discovery showed neither transparency nor fairness.
“Discovery uses its dominance of the market by bullying patients and healthcare providers in accepting substandard healthcare,” he said.
Public submissions on the Section 59 investigation close on Sunday, June 30.
Chaired by advocate Tembeka Ngcukaitobi, the probe follows allegations made by members of the National Health Care Professionals Association.