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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
08-07-2025
- Health
- IOL News
Medical schemes racially targeted black healthcare providers
Health Minister Aaron Motsoaledi received the final report from the Section 59 Investigation Panel on Monday. Image: Siyabulela Duda| GCIS A PANEL established to probe allegations of racial discrimination by medical schemes has detailed how black healthcare providers were unfairly targeted by 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 inquiry stems from public allegations made in May 2019 by members of the National Health Care Professionals Association (NHCPA) and Solutionist Thinkers, who alleged that medical schemes and administrators were unfairly withholding their claims based on race and ethnicity. An independent investigation panel, known as the Section 59 Inquiry and comprising Advocate Tembeka Ngcukaitobi SC (Chairperson), Advocate Adila Hassim, and Advocate Kerry Williams, probed the allegations, to identify trends and make recommendations that may require legal or policy interventions. The main focus of the investigation was on fraud, waste and abuse (FWA) and FWA systems, which refers to the systems used by the medical aid schemes and administrators to detect, investigate and determine providers who engage in FWA. This investigation sought to determine if there is a systemic flaw in the Schemes and Administrators FWA systems, particularly the part of the system which claws back monies for providers where the schemes have suffered loss. According to the report, the written submissions alleged that the schemes were intimidated and bullied providers through the implementation of their FWA systems, including by refusing to reimburse providers directly. The schemes were alleged to be treating providers unfairly and in particular were alleged to be targeting black providers. 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 Schemes' FWA systems all made use of software or algorithms that were designed to flag providers who were suspected of engaging in FWA. The FWA systems also all made use of other investigative techniques – staff within the Schemes would receive the details regarding providers who were flagged as engaging in suspicious FWA behaviour and thereafter would engage with these providers, often requesting additional information from the providers to test if they were correctly flagged. None of the Schemes relied entirely on their software or algorithms to determine if a provider was guilty of FWA.' A statistical analysis on the data found that across the board (regardless of the Scheme or Administrator involved; and generally in relation to almost all of the health care disciplines), black providers were much more likely than non-black providers to have been found guilty of FWA by the Schemes and Administrators concerned. This greater likelihood was measured in what has become known as a 'risk ratio'. 'The FWA system produces disparate outcomes based on race – demonstrates that there are probably errors in the FWA systems which must be corrected. For GEMS, black dental therapists in 2014 experienced risk ratios of between 2.7 and 3.27 – i.e. were generally approximately three times (300% more) more likely than non-black dental therapists to be guilty of FWA. For Discovery, black psychiatrists in 2017 experienced risk ratios of between 3.44 to 3.77 – i.e. black psychiatrists were generally approximately three and a half times (350% more) more likely than non-black psychiatrists to be guilty of FWA. For Medscheme, black anaesthetists in 2018 experienced risk ratios of between 6.39 and 6.78 – i.e. black anaesthetists were generally approximately six and a half times (650% more) more likely than non-black anaesthetists to be guilty of FWA. 'Much of the evidence placed before the Panel suggested that there may be systemic unfair discrimination in the implementation of the FWA systems by the Schemes. Systemic discrimination is an issue which has not been extensively addressed by our courts or administrative bodies.' The Panel recommended that there be full algorithmic transparency. 'We explained that the full workings of the algorithm should be visible, transparent and accessible to both the people who use algorithms but also to the people who are affected by the algorithmic systems. Specifically, it is necessary that the inputs into, and construction of, the algorithm should be known.'
The South African
07-07-2025
- Health
- The South African
Damning report confirms racial bias by SA medical aid schemes
A damning report by the Section 59 Investigation Panel has confirmed longstanding allegations of racial discrimination by South African medical aid schemes against black healthcare providers. The findings were handed over to Health Minister Dr Aaron Motsoaledi on Monday by panel chair Advocate Tembeka Ngcukaitobi. The independent inquiry was established following complaints lodged in 2019 by the National Health Care Professionals Association and Solutionist Thinkers, who alleged that claims by black practitioners were disproportionately withheld or scrutinised based on race and ethnicity. Ngcukaitobi confirmed that the panel found compelling evidence of systemic racial bias. 'Evidence of the risk ratios before us showed racial discrimination against black service providers by the schemes,' he said. 'Black is a generic term that includes Coloureds, Indians, and Africans.' Using a statistical tool called a risk ratio, the panel measured the likelihood of black practitioners being subjected to investigations and penalties compared to their Wwhite counterparts. At GEMS (Government Employees Medical Scheme) in 2014, Black dental therapists were 2.7 to 3.7 times more likely to be found guilty of fraud, waste, and abuse (FWA). (Government Employees Medical Scheme) in 2014, were to be found guilty of fraud, waste, and abuse (FWA). At Discovery Health in 2017, Black psychiatrists were 3.44 to 3.77 times more likely to be penalised than non-Black psychiatrists. These ratios translate to a 300-370% higher likelihood of black professionals being implicated in FWA cases. Beyond the racial disparity, the investigation also found that the procedures used by schemes in FWA inquiries lacked fairness and transparency. 'The FWA procedures for the recovery of monies allegedly owed are unfair, and they violate the rights to procedural fairness of individual practitioners,' said Ngcukaitobi. An interim report was previously submitted in 2021, but the final findings now confirm what many in the medical community have long argued – that black healthcare providers face disproportionate scrutiny under the current medical aid system. The release of the report is expected to prompt renewed calls for reform within the medical aid sector. Stakeholders are now awaiting the Health Minister's response and potential recommendations for systemic changes. The findings raise serious questions about equity, transparency, and accountability within South Africa's private healthcare administration. Let us know by leaving a comment below, or send a WhatsApp to 060 011 021 1 Subscribe to The South African website's newsletters and follow us on WhatsApp, Facebook, X and Bluesky for the latest news.
