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Medical aid to recoup R100m claimed 'fraudulently' by private hospital and doctors

By Bongani Nkosi Time of article published Jan 29, 2020

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Johannesburg - The State's biggest medical aid scheme has begun legal proceedings to claw back millions of rand it fraudulently lost to scores of private doctors and hospitals.

Money that the Government Employees Medical Scheme (Gems) sought to recoup from private practitioners could amount to over R100million.

The money was lost to syndicates of practitioners that claimed from Gems fraudulently between 2012 and 2019, according to Ishmael Mogapi, the scheme's operations risk manager.

Mogapi was part of Gems representatives who appeared at the inquiry probing allegations of racism black doctors were said to have suffered at the hands of medical aid schemes.

The Council of Medical Schemes (CMS), a statutory body, launched the inquiry following complaints by African and Indian medical practitioners that medical aid companies racially profiled and abused them.

The inquiry, chaired by renowned lawyer Tembeka Ngcukaitobi, continued at the offices of the CMS outside Pretoria on Tuesday.

The complaining black doctors previously told the inquiry that schemes played dirty when it was time to pay out their claims for work done. The dirty tricks included launching “illegal” probes on practitioners and withholding their pay when these continued.

Gems told the inquiry yesterday that it, in fact, fell victim to scores of unscrupulous practitioners operating in syndicates.

Its representatives assured the Ngcukaitobi panel that far fewer doctors would accuse it of racism, adding that Gems paid out claims and only recovered the money after it satisfied itself that the claim was fraudulent.

“We follow the legal route in everything we do,” Gems incoming principal officer Stan Moloabi said.

“We do not use cameras,” Moloabi said, referring to the clandestine way of gathering damning evidence against doctors schemes allegedly applied.

The amount that Gems believed was fraudulently paid out to practitioners and hospitals jumped from R812000 in 2012 to R86m in 2016. The 2015 figure was R68m, Mogapi revealed.

These are funds that Gems paid and then ordered practitioners to pay back because they were fraudulent. The fraud included claims for work not done. These were uncovered by investigations Gems had, he said.

One rehabilitation hospital in Malvern, Durban, paid Gems the R12m it had fraudulently claimed, the scheme said.

The inquiry continues on Wednesday.


The Star

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