Inquiry into alleged racial profiling grinds to a halt

A high-profile inquiry into alleged racial profiling by medical schemes and administrators has ground to a halt over an apparent impasse between the industry regulator and an investigating panel chaired by Tembeka Ngcukaitobi, with both sides accusing the other of delaying the process.

The Council for Medical Schemes (CMS) appointed the panel in 2019 in response to allegations from black healthcare providers that they were being treated unfairly by medical schemes based on race.

The inquiry was conducted in terms of section 59 of the Medical Schemes Act to determine whether there was racial discrimination against black health-care providers and whether they were being treated unfairly during fraud investigations. The interim report was released in January 2021, but the panel has yet to publish a final version.

Finalising the report is important for healthcare providers and the medical schemes industry because it is expected to deal with racial discrimination and the extent of the powers accorded to schemes in terms of section 59 to investigate fraud and claw back funds paid erroneously to service providers.

In response to MPs’ questions last week, CMS registrar Sipho Kabane blamed the threemember panel and said the council is considering taking legal action to compel it to complete its work.

“We have been knocking at the door of the chair and panel members. Up to now we have not been given that final report, and frankly we do not understand the reasons.

‘INACCURATE’

“They have not said to us ‘we are unhappy about this and that and are [therefore] not releasing the report’,” he told members of parliament’s portfolio committee on health on Thursday.

“We believe the only avenue left to us is to take the section 59 panel to court and ask the court to force them to release that report and explain why it has not released it up to now,” he said.

However, the panel hit back, saying Kabane’s statements to parliament were inaccurate and omitted material facts.

“The panel has always believed and continues to believe it is in the public interest to finalise and release the final report. In October 2021 the panel proposed a detailed work plan and budget for the completion of the final report. The proposal was not accepted by Dr Kabane, and there has been no communication to the panel from [him] ever since,” Ngcukaitobi said.

“As things stand, the ball is in Dr Kabane’s court. The panel has made clear what it requires to complete the report.”

Kabane said he stood by his comments to parliament. “We have not had a single correspondence from [the panel] saying ‘we are not releasing the report because of the following reasons’. If they are genuine I expect them to come to us and explain where the bottleneck is. We want the thing completed,” he said on Sunday.

FRAUD AND WASTE

Kabane conceded that the CMS had received a proposed plan for finalising the report, but said that the council had not accepted it because it had been put forward by panel members Adila Hassim and Kerry Williams, not Ngcukaitobi.

The Board of Healthcare Funders (BHF), an industry association for medical schemes and administrators, said it was

important to finalise the inquiry as it deals with financial arrangements between healthcare practitioners and funders.

“It is important that we get conclusion on the matter to [get] a common understanding of what section 59 means. Fraud, waste and abuse cost the industry about R30bn a year,” said BHF chair Katlego Mothudi.

The interim section 59 inquiry report said that from 2012 to 2019 black health-care practitioners investigated by Discovery, Medscheme and the Government Employees Medical Scheme were more likely to be found to have committed fraud, waste or abuse than their white counterparts, and that this constituted racial discrimination. However, the panel said it did not find evidence of deliberately unfair treatment, as there was no evidence of racial bias in the algorithms and methods used by schemes to identify fraud, waste and abuse.