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IOL News
12-07-2025
- Health
- IOL News
Is racial profiling undermining South African healthcare? A call for accountability and reform
The discrimination findings of a Section 59 report affected black healthcare professionals in disciplines such as physiotherapy, psychology, and social work, who are said to be 'more likely' to be guilty of fraud, waste, and abuse. Image: AI / Ron Apologies are necessary, but are not enough; material redress and structural consequences should be the next steps against medical schemes that racially profile black healthcare professionals. Healthcare workers union, Health & Other Services Personnel Trade Union of South Africa (Hospersa), expressed deep concern and condemnation following the announcement of the findings of the Section 59 Investigation Report in which three medical schemes, namely Government Employees Medical Scheme (Gems), Medscheme, and Discovery Health, applied discriminatory risk ratios to black health professionals. The discrimination affected black healthcare professionals in disciplines such as physiotherapy, psychology, and social work, who are said to be 'more likely' to be guilty of fraud, waste, and abuse (FWA). The panel reviewed statistical and testimonial evidence, and found that black providers were disproportionately flagged, audited, or penalised through opaque FWA systems. Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Next Stay Close ✕ The investigation was launched in 2019 after several healthcare providers made allegations that they were being unfairly treated by medical aid schemes based on race and ethnicity. The affected section relates to the payment of claims by black medical professionals. Hospersa spokesperson, Lindelwa Mdlalose, stated that the report confirmed the suspicions and personal experiences of many black healthcare professionals. The union called for remuneration and class action litigation against the medical schemes found to have applied such racial profiling, resulting in financial and reputational harm to individuals. Hospersa stated that the medical schemes should be held accountable and issue formal public apologies. It also sought a restitution framework, overseen by the Council for Medical Schemes (CMS), designed to review and remedy individual cases fairly, efficiently, and with a sense of urgency. 'As a union steadfastly committed to justice, equality, and transformation, Hospersa cannot allow this moment to pass without demanding full accountability, restitution, and long-overdue structural reform. 'To ensure that this injustice is never repeated, Hospersa calls for systemic changes across the private healthcare sector. All race-based profiling algorithms must be immediately discontinued and outlawed. Oversight mechanisms must be strengthened to enforce transparency and accountability in audit practices. Affected schemes must implement anti-bias training and submit to regular, independent audits of their fraud detection and disciplinary systems,' said Mdlalose. The union said the issuance of the findings and recommendations of the Section 59 report 'must serve as a turning point'. 'The Section 59 Report is more than an indictment of past practices, it is a call to action. Racial profiling in the healthcare sector is a betrayal of both ethical norms and constitutional values. It undermines professional dignity and perpetuates racial injustice under the excuse of fraud detection.' Meanwhile, Discovery Health strongly disagreed with the findings and called on CMS to carefully review the panel's conclusions to prevent harm to medical scheme members and the long-term viability of medical schemes. Discovery Health CEO, Dr Ron Whelan, said the conclusions from the investigation are 'based on flawed methodology, unscientific assumptions, and misinterpretation of complex data'. Dr Whelan said they are currently reviewing the report in full and considering their options, including a formal review of the findings, which drew numerous conclusions that, according to Dr Whelan, is not supported by credible evidence. Discovery Health said: 'No evidence has been presented to support the allegations that (we have) investigated or sanctioned any healthcare professional in a biased or unjustified manner. In fact, the panel's own interim report in 2021 confirmed that the processes used by medical schemes were legally sound and showed no explicit evidence of racial bias. 'Furthermore, all complaints submitted to the Section 59 Panel by healthcare providers against schemes administered by Discovery Health were shown to have legitimate grounds for investigation, with no evidence of racial profiling.' Gems said over the past three years, since the release of the Interim Section 59 Panel Investigations, they have 'taken comprehensive steps to strengthen its FWA management framework to eliminate any potential for disparate outcomes'. According to the medical scheme, after the interim report made several recommendations, they have already begun to implement policies which 'largely reflect reforms'. Gems principal officer, Dr Stanley Moloabi, said: 'It is reassuring that the panel has found no evidence that GEMS acted with racist intent. This distinction is critical - structural outcomes must not be confused with deliberate discrimination. '(We) will continue to work closely with the CMS, healthcare providers, and members to ensure that our FWA systems are transparent, fair, and compliant to all laws and regulations of the Republic of South Africa.' Enquiries to Medscheme had not been answered by deadline. During a portfolio committee meeting held on Friday, Health Minister Aaron Motsoaledi pointed out the 'silence' in the National Health Act regarding remuneration or corrective measures to be taken in cases where discrimination against health professionals is identified. He also called for algorithm and software transparency in which the department is able to be privy to information regarding risk ratios against black health professionals.
IOL News
10-07-2025
- Health
- IOL News
Health bodies urge implementation of report on racial bias in medical aid schemes
The fight for fair treatment of healthcare providers is far from over. Image: File 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
IOL News
07-07-2025
- Health
- IOL News
Probe finds evidence of racial bias against black healthcare providers by South Africa's medical schemes
Health Minister Dr Aaron Motsoaledi has received the long-awaited report which confirmed allegations of racial discrimination and unfair practices by some of South Africa's leading medical schemes against Black healthcare practitioners. Image: Oupa Mokoena / Independent Newspapers The Board of Healthcare Funders (BHF) has firmly rejected the long-awaited Section 59 report, which on Monday found positive and glaring alleged racial bias and discrimination by medical health schemes against black health professionals. Presented by panel chair Advocate Tembeka Ngcukaitobi, the report found systemic procedural unfairness and a deeply entrenched power imbalance that over the years has disproportionately and negatively impacted black medical professionals. The inquiry commissioned by the Council for Medical Schemes (CMS), launched in 2019, scrutinised practices by medical aid schemes such as Discovery, Medscheme and the Government Employees Medical Scheme (GEMS) between 2012 and 2019. "We confirm the findings and recommendations in the interim report, that the procedure followed by medical schemes when they claw back monies allegedly owed by practitioners or when they investigate instances of fraud, waste, and abuse is unfair," said Ngcukaitobi. On Monday, Minister of Health Dr. Aaron Motsoaledi, made the report public after receiving the investigation report on the findings of the inquiry conducted by the Section 59 Investigation Panel into allegations of racial discrimination by medical schemes. The inquiry was launched after doctors and other practitioners accused medical aid administrators of unfairly targeting them with audits, delaying payments or terminating contracts without clear justification. This comes after some black healthcare providers and members of Solutionist Thinkers and the NHCPA (National Health Care Professionals Association), in 2019, made allegations that they were being treated unfairly by schemes and administrators, based on race and ethnicity. The written submissions alleged that the schemes were intimidating and bullying providers through the implementation of their FWA systems (used by schemes and administrators to detect, investigate and determine providers), including by refusing to reimburse providers directly and coercing them into agreeing to acknowledgment of debt (AODs). The schemes were alleged to be treating providers unfairly and in particular were alleged to be targeting black providers. The NHCPA explained that it had anecdotal evidence that the schemes' forensic audit process was more prevalent among black providers and pointed out that the panel could obtain empirical information through its investigation. The report's statistical risk ratios developed during the investigation found that black practitioners were significantly more likely to be flagged, investigated, and penalised compared to their white counterparts. It found that in 2014 at GEMS black dental therapists were up to 3 times more likely to be flagged, while for Discovery in 2017, the report found that black psychiatrists were 3.5 times more likely. For Medscheme in 2018, the report suggests that black anesthetists were 6.5 times more likely to be found guilty of fraud, waste, and abuse (FWA). "Let me repeat this, we were not a court, we did not adjudicate individual complaints, we did not run a trial and make findings about unfair discrimination in terms of Section 9 or the Pepuda Act, we only considered the facts and the facts lead us to one conclusion that the evidence of the risk ratios before us showed racial discrimination to black service providers by the schemes. "These risk ratios are not scientific certainties, but they are highly probable indicators of discrimination," Ngcukaitobi added. While still studying the report, the BHF, a nonprofit company representing medical schemes and administrators, said it firmly rejects the findings of the final Section 59 investigation. "We still need to study the final report; however, we are disappointed that the Section 59 Inquiry panel has confirmed that it has upheld the findings made in the interim report released in 2021. We believe these findings are demonstrably and fundamentally flawed and, if allowed to stand, will open the door for runaway fraud and corruption in the healthcare sector," it said. On alleged fraudulent claims, the BHF stated: "Fraudulent claims, over-servicing, abuse of benefits, and improper billing practices cost South Africa's medical schemes around R30 billion each year. These losses directly impact the contributions and benefits of 9.7 million scheme members, the majority of whom come from historically disadvantaged communities. Fraud, waste, and abuse (FWA) inflate healthcare costs, reduce member benefits, and drive up premiums, placing disproportionate financial strain on working-class families." The issues the BHF raised with the panel's methodology included: Unscientific methods to assign race, using surnames to categorise providers; Failing to account for exposure bias, which occurs when a group is more likely to be involved in a process or activity simply because of greater contact or interaction; and Confusing correlation with causation, by assuming discrimination without 'rigorously considering other relevant variables such as provider billing patterns, patient load, or socioeconomic contexts'.
The Star
14-05-2025
- The Star
Limpopo pharmacist released on bail after alleged R1 million medical aid fraud
A Limpopo pharmacist, accused of a significant medical aid fraud scheme costing GEMS nearly R1 million, has been released on bail. A Limpopo pharmacist accused of orchestrating a brazen medical aid scam that cost the Government Employees Medical Scheme (GEMS) nearly R1 million has been released on R5 000 bail. According to Limpopo police spokesperson Colonel Malesela Ledwaba, GEMS opened a fraud case in April 2024 against a 40-year-old suspect. This followed allegations that the man approached medical aid members, promising them cashback and Green Cross shoes in exchange for their details, which were later used to submit fraudulent claims. Ledwaba revealed that Tinyiko Gift Mangolele, the owner of a pharmacy in Malamulele, went as far as unlawfully using the identities of unsuspecting medical doctors to file fraudulent prescription claims. These deceitful actions were carried out without the doctors' knowledge or approval, exploiting their professional credentials to orchestrate an elaborate scheme that further deepened the extent of the scam. 'Furthermore, Mangolele, the owner and director of a pharmacy at Malamulele, used the information of two medical doctors without their permission to claim medication that needed the doctors' prescription.' Ledwaba further stated that, 'Through intensive investigation conducted, it was further established that other members of GEMS never consulted with the doctors but claims were made on their behalf.' For four long years, the pharmacy owner carried out a calculated scheme, relentlessly defrauding the medical aid and siphoning off vast sums, causing a devastating financial blow to GEMS. 'As a result, the Medical Aid suffered a total loss of nine hundred and ten thousand rands (R910,000) between January 2018 and September 2022,' Ledwaba said. He further revealed that, following a meticulous investigation, the suspect was finally apprehended by members of the Provincial Commercial Crime Unit in the Malamulele policing area on May 12. The suspect is set to make his second appearance at the Giyani Specialised Court on 29 May, while police investigations into the matter continue. The Star [email protected]
IOL News
14-05-2025
- IOL News
Limpopo pharmacist released on bail after alleged R1 million medical aid fraud
A Limpopo pharmacist, accused of a significant medical aid fraud scheme costing GEMS nearly R1 million, has been released on bail. A Limpopo pharmacist, accused of a significant medical aid fraud scheme costing GEMS nearly R1 million, has been released on bail. A Limpopo pharmacist accused of orchestrating a brazen medical aid scam that cost the Government Employees Medical Scheme (GEMS) nearly R1 million has been released on R5 000 bail. According to Limpopo police spokesperson Colonel Malesela Ledwaba, GEMS opened a fraud case in April 2024 against a 40-year-old suspect. This followed allegations that the man approached medical aid members, promising them cashback and Green Cross shoes in exchange for their details, which were later used to submit fraudulent claims. Ledwaba revealed that Tinyiko Gift Mangolele, the owner of a pharmacy in Malamulele, went as far as unlawfully using the identities of unsuspecting medical doctors to file fraudulent prescription claims. These deceitful actions were carried out without the doctors' knowledge or approval, exploiting their professional credentials to orchestrate an elaborate scheme that further deepened the extent of the scam. 'Furthermore, Mangolele, the owner and director of a pharmacy at Malamulele, used the information of two medical doctors without their permission to claim medication that needed the doctors' prescription.' Ledwaba further stated that, 'Through intensive investigation conducted, it was further established that other members of GEMS never consulted with the doctors but claims were made on their behalf.' For four long years, the pharmacy owner carried out a calculated scheme, relentlessly defrauding the medical aid and siphoning off vast sums, causing a devastating financial blow to GEMS. 'As a result, the Medical Aid suffered a total loss of nine hundred and ten thousand rands (R910,000) between January 2018 and September 2022,' Ledwaba said. He further revealed that, following a meticulous investigation, the suspect was finally apprehended by members of the Provincial Commercial Crime Unit in the Malamulele policing area on May 12. The suspect is set to make his second appearance at the Giyani Specialised Court on 29 May, while police investigations into the matter continue. The Star
