The anti-competitive allegations were made by the Private Ambulance Services Association (Pasa), which claims that Netcare 911 “is killing their small businesses” through an “unfair” arrangement that Netcare 911 has with 37 medical aid schemes.
It claims the arrangement sees Netcare 911 assessing claims of its competitors affiliated to Pasa, which has a membership of 12 companies, and deciding on whether its competitors should be paid for services rendered.
The investigation into Netcare 911, a wholly owned subsidiary of listed health group Netcare Limited, will form part of the Competition Commission's inquiry into the health sector launched earlier this year to ascertain whether there are unfair market practices in private healthcare.
Pasa chairperson Malebo Mabalane said their organisation's main concern was how Netcare 911 was rejecting Pasa’s claims that supposedly met Netcare’s own guidelines, as to what constitutes an emergency.
“Netcare tells us that abdominal pains, maternity issues and dizziness are not emergencies. Now we sit back and ask ourselves: 'How can you say maternity is not an emergency? How can you say abdominal pain or dizziness is not an emergency?'
“I cannot tell a patient that he or she is not dying. I cannot leave a patient behind, but that is what Netcare 911 wants us to do.”
Sipho Mntombeni of the health market inquiry acknowledged that Pasa’s complaint would form part of the inquiry into unfair practices.
According to an email signed by senior Netcare 911 managers Carl de Montille and David Stanton, factors that Netcare 911 considers an emergency include an emergency that requires immediate surgical or medical treatment. If not immediately treated, the email added, several things could happen to a patient, including death or impairment of a bodily function.
However, the chief financial officer at Supreme Care EMS, Inocentia Nyawose, provided evidence to The Star of a rejected “emergency” claim, where the patient who received assistance from Supreme Care had to motivate on behalf of Nyawose’s company for it to be paid by Netcare 911 for services rendered.
The patient, who is from Katlehong in Ekurhuleni, was hospitalised for almost two weeks with severe headaches caused by her clinical depression.
But Netcare 911 rejected this claim because it was a “non-emergency use of an ambulance”, according to Stanton. “I could not drive myself to hospital as I was feeling dizzy. I was then transported by Supreme Care to Botshelong Hospital. I'm currently still admitted at Akeso Clinic in Alberton,” the patient wrote to Netcare in motivation.
But Netcare 911’s case manager Natalie Hartnady allegedly rejected the motivation and closed the case. The rejected amount, which Hartnady said Nyawose should recoup from the patient, was roughly R1 200, according to Supreme Care’s credit controller Rosina Alfandika.
Speaking to The Star, Netcare 911’s managing director Craig Grindell said they conduct thorough checks on claims to all providers to ensure that the correct clinical care was provided as defined in the Medical Schemes Act. “Claims are only ever downgraded or not paid if the services were not provided or were rendered for non-emergency conditions In each case, full and transparent feedback is provided to the external providers.”
Asked whether this arrangement fostered anti-competitiveness and hindered new entrants, Grindell said their scheme clients appointed them because of Netcare 911’s superior resources, and the arrangement did not contain any “exclusivity provisions”.
A spokesperson for the Council of Medical Schemes acknowledged the existence of the arrangement and said there was “no sound reason why medical schemes should not contract with independent providers if they are capable of servicing their members in all geographic areas where they reside”.