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CMS Section 59 Investigation: Deadline for Public's Submissions on Alleged Medical Aid Racial Profiling
The public, including entities, institutions, associations and organs of state have until the 19th of July 2019, to make submissions on the Section 59 investigation into allegations of racial profiling against Black, Coloured, and Indian private medical practitioners.
Advocate Thembeka Ngcukaitobi chairs this investigation. The probe follows allegations made by members of the National Health Care Professionals Association (NHCPA) that they had been unfairly treated and had their claims withheld by medical aid schemes based on race and ethnicity.
The investigating panel will probe allegations of racial profiling, blacklisting for payments, blocked payments, demands of confidential clinical information, "bullying and harassment, coercion, entrapment and use of hidden cameras".
Section 59 of the Medical Schemes Act states as follows:
Recovery of benefits paid bona fide to a practitioner who was not entitled to receive such benefits
Section 59(3) of the Medical Schemes Act empowers the medical scheme to recover any amount which has been paid bona fide to which a practitioner is not entitled to or any loss which has been sustained by the medical scheme through theft, fraud, negligence or any misconduct which comes to the notice of the medical scheme. The question is: How does the medical scheme recover such an amount? By deducting such amount from any benefit payable to the health practitioner.
The legal status of payment arrangements made between health practitioners and medical schemes
The payment arrangements between practitioners and the scheme are legally binding if they are lawful. For example, an unlawful agreement is one which is reached with the condition that the medical scheme will not report a practitioner to any organ of state, including the HPCSA on a matter that such an organ of state has jurisdiction over. Although medical schemes may exercise their choice in terms of reporting unprofessional conduct to the HPCSA, they have a duty in terms of common law and section 66 of the Medical Schemes Act to report practitioners to the HPCSA.
Withholding of claims due to practitioners by medical schemes
In terms of Section 59(2) of the Medical Schemes Act, the scheme should pay a claim either to the member or practitioner within 30 days of receiving the claim. According to Regulation 6 of the Medical Schemes Act Regulations, if a medical scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, it must inform both the member and the relevant health care provider within 30 days after receipt of such account, statement or claim that it is erroneous or unacceptable for payment and state the reasons for such an opinion and the member or health practitioner has sixty days to correct and resubmit such account or statement. Where the medical scheme has failed to either notify the member or health care provider within 30 days that an account/statement/claim is erroneous or unacceptable for payment, OR fails to provide an opportunity for correction and resubmission, the medical schemes bears the onus of proving that such account/statement/claim is, in fact, erroneous or unacceptable for payment when there is a dispute. Practitioners are advised to report medical schemes who unlawfully withhold claims due to them to the Council for Medical Schemes.
Should you have information to submit for the investigation, please send to cmsinvestigation@medicalschemes.com
Written submissions must be concise and should include a brief summary. Factual information to be placed before the investigating panel must be attested to by an affidavit.
SAMA Members on the Steering Committee
Dr Mvuyisi Mzukwa Dr Vusumuzi Nhlapho (Alternate)
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