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DURBAN - A doctor is taking legal action against a medical aid scheme for allegedly extorting money and withholding payments. 

Medscheme has been reported to the Council for Medical Schemes and its forensic unit to the SA Institute for Chartered Accountants by a prominent specialist in Durban who did not want to be named. 

The doctor is pursuing legal action over payments withheld for three months. He claimed Medscheme had requested R500 000 to resume payments.  The doctor alleged payments had been withheld because the medical aid suspected fraud but had not provided him with proof.

He said he ran an ethical practice and would not be bullied.  His case was not isolated. 

Another Durban doctor who agreed to pay a portion of what was required by the scheme, said his payments resumed immediately. The scheme then deducted the cash from what was owed to him.  He alleged the scheme was targeting doctors by making “ridiculous” demands for information dating back three years.

The National Health Care Professionals’ Association has taken up the cause of payment problems on behalf of more than 250 health-care workers, including doctors, pharmacists and physiotherapists.  The association said similar problems were experienced with 19 medical schemes. 

It had approached the North Gauteng High Court to have the schemes  withholding of payments declared illegal. 

Attorney Dennis Sibuyi, who is representing the doctors, said a trend has been noted. 

“Medical schemes have started randomly targeting doctors, make up allegations against them and then approaching them for exorbitant payments.  They stop payments when doctors decide to challenge them. They request information like source documents going far back in time and I know doctors who run busy practices would not have that information available,” said Sibuyi.

He said medical schemes had no right to withhold payments from doctors, affecting their livelihoods, without sufficient evidence that fraud had been committed.

He said some companies were using “spy tapes” to set up doctors in an attempt to gather information to use against them.  But medical aid schemes said medical aid fraud affected their members. 

Responding to the allegations, Medscheme chief executive Kevin Aron said the schemes paid claims up front in good faith.  

“We then check that the claims and payments made were correct in line with the treatment provided and the scheme rules.  Medscheme’s approach is to investigate mainly wastage and abuse, as fraud requires proof 
of intent.  We have the software to evaluate various elements of claims, including  treatment regimes, average duration and numbers as well as average claims in each area of specialisation,” said Aron. 

He said delays occurred when a service provider would not allow claims to be validated. “Only then would we withhold payment. In instances where we have proven intentional abuse, we ask the doctor to pay back the funds not due. Where there is fraud, we report to the HPCSA (Health Professions Council of SA) for sanctioning and to the SAPS for criminal prosecution.” 

The country’s biggest medical aid scheme, Discovery Health, said fraud had a direct impact on health-care costs, raising premiums for members and making health care less affordable.

“Discovery Health views fraud as a serious criminal offence. We work tirelessly with stakeholders to take all the necessary action, where appropriate, to counter fraud so that it does not affect members’ premiums,” said chief executive Jonathan Broomberg. 

The Government Employees’ Medical Scheme’s principal officer Dr Gunvant Goolab said 127 service providers had been sanctioned for fraud this year, 45% of them based in KwaZulu-Natal. 

“Should abuse and fraud go undetected and unaddressed, the additional financial burden from this would unfortunately contribute to higher premiums for members.”