Discovery denies racial profiling in members’ letter
• Race is coincidental, CEO says of probe into abuse
Discovery Health, SA’s largest private medical schemes administrator, has published a letter to its members in which it says there was no racial discrimination in its fraud, waste and billing abuse processes. The letter, signed by Discovery Health CEO Ryan Noach and the principal officer at Discovery Health Medical Scheme, Charlotte Mbewu, said that a minority of health practitioners act dishonestly and their racial demographics are coincidental.
Discovery Health, SA’s largest private medical schemes administrator, has published a letter to its members in which it says there was no racial discrimination in its fraud, waste and billing (FWA) abuse processes.
The letter, signed by Discovery Health CEO Ryan Noach and the principal officer at Discovery Health Medical Scheme, Charlotte Mbewu, said a minority of health practitioners act dishonestly and their racial demographics are coincidental.
The company, which covers 3.5-million people through its 19 schemes and is part of the larger Discovery group, was responding to findings of an investigation into racial profiling commissioned by the industry regulator, the Council for Medical Schemes (CMS).
Almost 9-million South Africans are members of medical schemes.
The investigation was launched in 2019 in terms of section 59 of the Medical Schemes Act, after complaints by black medical practitioners that they were being unfairly targeted.
The CMS has said it spent more than R11m on the probe.
An interim report released last Tuesday claimed that the Government Employees Medical
Scheme (Gems), SA’s biggest medical scheme for public servants, and the two biggest medical scheme administrators, Discovery Health and Medscheme, were 1.4 times more likely to conclude that black health-care practitioners had committed FWA than their white counterparts.
Discovery Health said because the report had not been shared with the company before it was published online, it has had insufficient time to examine it.
“Now that the report is open to the public, we will study the findings and recommendations in detail. We will comment further on the report within the six weeks set out for medical schemes to do so,” it said.
The panel found unfair racial discrimination in forensic investigations into FWA by the medical scheme industry.
Discovery Health said this was based on the fact that there was a higher percentage of black, Indian and coloured health-care professionals among those who, after the forensic investigations, were found to have breached industry rules in their billing processes.
Discovery said it welcomed the finding by the panel that while results were more likely to find black and Indian health professionals guilty, the algorithms and processes used were not racially biased.
“The panel reached this conclusion even though there was no specific evidence of even a single case where they found the method or approach used to identify and investigate the FWA to be inappropriate,” Discovery Health said.
It said the panel was clear in recognising that there was no evidence of deliberate, explicit racial bias in the methods and algorithms the medical schemes and their administrators used to identify and investigate the abuse.
Discovery Health said a small number of health-care professionals were investigated for FWA practices and had to pay money back to medical schemes.
Most health-care professionals focused on delivering excellent care, showing a committed and honest work ethic, it said.
At the 2019 FWA summit, the CMS said FWA claims may account for up to 15% of claims medical schemes pay out.
NOW THAT THE REPORT IS OPEN TO THE PUBLIC, WE WILL STUDY THE FINDINGS AND RECOMMENDATIONS IN DETAIL Discovery Health Medical scheme
A total of R22bn-R28bn in medical scheme members’ funds paid towards their medical scheme membership could be lost to fraudulent claims annually.
Discovery Health said FWA against its 19 medical scheme clients comprise 3%-7.5% of claim amounts annually.
“Medical schemes have a duty to make sure that members’ money is treated with due care and to make sure that they only pay valid medical claims.
“If we fail to achieve this, it is not only a breach of the scheme’s commitment to you our members, but it also leads to increases in your scheme contributions, and it can make schemes unaffordable,” Discovery Health said.