Skip to main content

'Medical aid schemes have become a law unto themselves'


Medical aid schemes have become a law unto themselves with untold power to determine which private doctor practices in the country should close shop.

President of Health Professions Council of SA (HPCSA) Dr Kgosietsile Latlape made this scathing submission on Wednesday at the hearings investigating allegations that medical schemes racially profiled African and Indian medical practitioners.

 Black doctors canvassed the Council for Medical Aid Schemes to launch the investigation.

The hearing is being held in Centurion and chaired by advocate Tembeka Ngcukaitobi.

The doctors cried foul after medical schemes refused to pay them and instead accused them of fraud when they submitted their claims.

A doctor, asking for anonymity, told The Star at the sidelines of the hearing that one medical scheme had withheld R100000 since 2006 claiming to have flagged the claim.

A fervent Letlape launched his scathing criticism of the medical schemes, lending clout to allegations by black practitioners of abuse when it was time to pay up.

Doctors have suffered gross abuse of power at the hands of the schemes who launched illegal fraud investigations when they wanted their money, blasted Letlape.

The schemes took advantage of the fact that there was no legislation compelling them to pay private doctors, nor were there agreed tariffs in the sector, said Letlape.

The so-called designated service providers (DSPs), which was a group of practices preferred by medical aids, were flourishing to the detriment of many practices.

“Now, being paid depends on the mood of the administrator.

"You have no legal right to be paid by the funder, irrespective of how you behave or what you do,” added Letlape.

“It’s further abuse of power where you decide as a medical aid which doctor is going to live and which one is going to die.

“That’s an abuse of power. The initial system was open and fair. Patients chose (their preferred doctor).

“Now its administrators that choose a doctor. So, people will be moved from Soweto to a service provider in Kempton Park,” said Letlape.

“This is where racial profiling is about the demographics of the country, about the history and about the situation of people.

“So, whether you call it racial-profiling or not what they do will affect black practitioners in general and black patients in particular.”

The schemes disregarded issues such patients’ taxi fares, the relationship with their old doctor and language barriers.

“Actually, medical aids are stealing patients from practitioners, planting them with other practitioners,” said Letlape.

“Why? Because they can.

“DSPs are uncompetitive, unlawful, unethical and discriminatory.

"They should not be allowed," added Letlape.

Schemes often resorted to illegality in their fraud investigations of doctors they don’t want to pay, Letlape declared.

He said while he would not deny that there were issues of fraud among doctors, the matter should be looked at broadly.

“But what I find fascinating is that every time they target a person, they do it unlawfully.

“And when they catch them they go to an agreement of repayment with that person,” said Letlape.

“By the time you refer it to the regulator you’re dealing with a poisoned chalice, where evidence has been obtained unlawfully. But people have already made deals.”

The National Healthcare Professionals' Association accused medical schemes of profiteering.

Donald Gumede, the association's chairperson, cited Discovery as an example, making a profit of over R600million last year.

“It is in pursuit of these super profits that medical practitioners have become easy pickings and cash cows for extortion by the schemes through fabricated allegations of fraud,” Gumede said.

The hearing continues on Thursday with medical aid schemes expected to state their defence.