A flood got my invoices, and other tall sto­ries doc­tors tell

Court case re­veals why med­i­cal aids dis­trust some doc­tors

Sunday Times - - News Health - By KATHARINE CHILD

● The (sur­gi­cal) gloves are off in a row pit­ting med­i­cal aid fund ad­min­is­tra­tors against health pro­fes­sion­als.

A le­gal bat­tle be­tween the two groups be­ing fought in the High Court in Pre­to­ria cites sev­eral cases of ap­par­ent cheat­ing by doc­tors — in­clud­ing one who said his fi­nan­cial records had dis­ap­peared in a flash flood.

The Na­tional Health­care Pro­fes­sion­als As­so­ci­a­tion launched the ac­tion last year, ac­cus­ing med­i­cal aid schemes of wrong­fully with­hold­ing pay­ments to its mem­bers.

Doc­tors, ther­a­pists and phar­ma­cists rep­re­sented by the as­so­ci­a­tion say they are be­ing bul­lied by the “vig­i­lan­tism” of med­i­cal aids.

But the med­i­cal aid ad­min­is­tra­tors, rep­re­sent­ing nearly 20 schemes, have given de­tails in their re­spond­ing court pa­pers about why they acted as they did in spe­cific cases.

For ex­am­ple, Cen­tu­rion GP Dr Gene Ra­mon­tja is ac­cused of hir­ing an un­qual­i­fied “doc­tor” for four years to treat his pa­tients, while claim­ing more than R1-mil­lion from med­i­cal aid schemes.

Ac­cord­ing to the court pa­pers he “ad­mit­ted the contravention” and signed an ac­knowl­edge­ment of debt to Med­scheme, an ad­min­is­tra­tor for mul­ti­ple med­i­cal aids.

Ra­mon­tja, who re­mains reg­is­tered with the Health Pro­fes­sions Coun­cil of South Africa, did not re­spond to queries.

Also still prac­tis­ing is Dr Ed­win T Mabuza from Lim­popo, who Dis­cov­ery al­leges de­frauded the scheme of more than R1.1-mil­lion up un­til April by claim­ing for medicines he did not dis­pense.

Dis­cov­ery Health re­fused to pay him for treat­ing its pa­tients for six months, al­most forc­ing him out of busi­ness.

He was asked by foren­sic in­ves­ti­ga­tors to prove he owned the ul­tra­sound ma­chines he said he used to treat pa­tients, and to pro­vide invoices for medicines he bought and dis­pensed.

He ex­plained his invoices for the medicines had been “washed away in a flash flood”.

He was told he could get du­pli­cates from the sup­plier but he said the “sup­plier had ab­sconded in the night”, ac­cord­ing to the court pa­pers.

Mabuza told the Sun­day Times noth­ing he gave Dis­cov­ery would sat­isfy the com­pany and he felt “vic­timised” be­cause it had au­dited him three times. He de­nied hav­ing com­mit­ted fraud.

He said he felt black doc­tors were be­ing racially pro­filed. “Are all white doc­tors hon­est?”

Dis­cov­ery Health has black­listed Jo­han­nes­burg doc­tor Maidi Teffo, who it de­scribes in the court pa­pers as “a high-risk” and “ha­bit­ual of­fender”.

Ac­cord­ing to the pa­pers, Teffo signed an ac­knowl­edge­ment of debt to the tune of R120 000 in 2008 af­ter claim­ing for items not dis­pensed to pa­tients. Five years later Teffo ac­knowl­edged debts of R920 000 af­ter he was found to have claimed for much more ex­pen­sive items than he had ac­tu­ally dis­pensed.

In April last year Dis­cov­ery Health asked him about claims lodged since 2013 to­talling R644 824 that it sus­pected were ir­reg­u­lar.

Teffo said talk­ing about Dis­cov­ery Health “made him de­pressed” and de­nied wrong­do­ing. He re­fused to com­ment fur­ther on the ad­vice of his lawyer.

Med­scheme and Dis­cov­ery Health say they only do au­dits on “out­liers” whose claims are flagged by so­phis­ti­cated foren­sic soft­ware.

The soft­ware picks up doc­tors who claim sig­nif­i­cantly more than sim­i­lar doc­tors do, health work­ers who dis­pense large amounts of un­usual medicines, and those who treat pa­tients for more than 24 hours in one day.

Dis­cov­ery Health CEO Jonathan Broomberg said no doc­tors were tar­geted un­fairly.

“Dis­cov­ery Health iden­ti­fies po­ten­tial fraud mainly through the use of so­phis­ti­cated al­go­rithms to an­a­lyse claims pat­terns. We do not use race, gen­der or any other de­mo­graphic fac­tors in our in­ves­ti­ga­tions.

“We only take clear ac­tion, in­clud­ing with­hold­ing pay­ments, where there is proven ev­i­dence of fraud, and then only af­ter full en­gage­ment with the provider and their ad­vis­ers.”

The court case re­sumes next month.

Dis­cov­ery Health CEO Jonathan Broomberg

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