Health bodies urge implementation of report on racial bias in medical aid schemes

Several years in the making, the fight for justice in South Africa’s healthcare sector is far from over. Health bodies say the real test now lies in the implementation of key recommendations from a landmark report, which found that black healthcare providers were unfairly targeted by medical schemes often having their claims withheld based on race and ethnicity.

Health Minister Aaron Motsoaledi received the final report from the Section 59 Investigation Panel on Monday. 

The investigation, commissioned in 2019, examined allegations of racial discrimination and procedural unfairness in the application of Fraud, Waste and Abuse (FWA) processes by major schemes and administrators, including Discovery Health, Medscheme, the Government Employees Medical Scheme (GEMS). Covering the period from 2012 to 2019, the Panel reviewed statistical and testimonial evidence and found that black providers were disproportionately flagged, audited, or penalised through opaque FWA systems. 

The report also detailed serious procedural shortcomings. These include failure to notify providers of alleged irregularities within a reasonable timeframe, audits that stretch back more than three years, the use of non-transparent algorithms and risk-rating tools, and the absence of independent mediation or effective appeal mechanisms. 

National Health Care Professionals Association (NHCPA) chairperson Dr Donald Gumede, who was among the complainants in the matter, welcomed the release of the report. 

“We are very excited that the final report has finally come to light,” said Gumede. “What’s critical now is the implementation because the report, at the end of the day, is just a document with recommendations. It’s what happens next that matters.”

He welcomed the proposal for a tribunal, saying: “There needs to be a proper system in place to regulate the entire healthcare chain. Right now, medical aid schemes operate like a law unto themselves. They are not accountable to anyone and they've destroyed many lives.”

Gumede added that they still receive complaints from healthcare professionals and acknowledged that reaching this point had been no easy feat.

The South African Medical Association (Sama) welcomed the release of the long-awaited final report and said it had been an active participant throughout the inquiry process. 

“The Report validates what many of our members have endured for years: racially skewed targeting, opaque algorithms, and Kafkaesque audit processes,” said Sama chairperson, Dr Mvuyisi Mzukwa.

“Sama has zero tolerance for any form of racial discrimination. Our members have a right to fair treatment, regardless of their race, and patients deserve a health system built on equity and accountability. We urge all medical schemes to act decisively and transparently. South Africa cannot tolerate discrimination masquerading as fraud control. Sama stands ready to work with all stakeholders to restore fairness, trust and accountability in our healthcare financing system.” 

Sama said they supported the panel’s call for urgent remedial action; legislative, regulatory, and operational, to eliminate discrimination and ensure fairness.

“The association has called on the Council for Medical Schemes (CMS) to publish an implementation roadmap within 60 days; on medical schemes and administrators to institute a moratorium on recoveries for claims older than three years until updated rules are adopted; and on the National Department of Health to accelerate long-overdue amendments to the Medical Schemes Act that would require algorithmic transparency and the establishment of independent dispute-resolution mechanisms.”

Discovery, Medscheme and the CMS did not respond to requests for comment by deadline.

Cape Times