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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
Yahoo
22-04-2025
- Health
- Yahoo
Louisiana will turn to AI to detect Medicaid fraud, health officials say
On his first day on the job Monday, Louisiana Department of Health Secretary Bruce Greenstein announced the launch of two initiatives – one to target Medicaid fraud and another to reduce the number of overdose deaths during pregnancy. The University of Louisiana at Lafayette is developing an artificial intelligence and data analysis tool the Louisiana Department of Health will use to fight 'fraud, waste and abuse,' state officials said. The university is developing the technology that could be deployed within a week to begin looking for instances of fraud in the Medicaid program, ULL Vice President for Research Ramesh Kolluru said in an interview. 'We are committed to improving government efficiencies in Louisiana using innovation,' Kolluru said. 'Our first mission … is to improve efficiency and integrity of the Louisiana Medicaid program.' The state health department has created a 'Fighting Fraud, Waste and Abuse' task force to detect wrongdoing within Medicaid, Undersecretary Drew Maranto said. The agency will partner with LA DOGE, Louisiana Gov. Jeff Landry's version of Elon Musk's controversial Department of Government Efficiency. A Medicaid fraud control unit already exist The AI technology is being trained on national data and peer-reviewed publications that have identified fraud, and it will then be tasked with finding similar patterns in Louisiana's Medicaid data, Kolluru said. Staff within the Louisiana Department of Health will verify any findings, he added. Maranto said the department will also be working with the state Office of Motor Vehicles to check if any Medicaid recipients have active drivers licenses in other states, which could help them determine their eligibility to receive Medicaid benefits in Louisiana. ULL's work on the AI program will not cost the health department because it already contracts with the university for other computing projects, Kolluru said. ULL will also partner with the state Office of Technology Services to 'modernize Louisiana Medicaid systems,' Kolluru said. SUBSCRIBE: GET THE MORNING HEADLINES DELIVERED TO YOUR INBOX In addition to detailing the counterfraud measures, Greenstein said the state has set a goal to reduce drug overdose deaths during pregnancy by 80% over the next three years. Overdose deaths have been the leading cause of maternal mortality in Louisiana since 2018, LDH Deputy Secretary Dr. Pete Croughan said. The new initiative, Project MOM (Maternal Overdose Mortality) will push to increase the availability of naloxone and buprenorphine, medications that can halt the effects of opioid overdoses when administered promptly. Other goals include more training health care providers on opioid use disorders and using money from settlements with opioid manufacturers to expand residential treatment facilities and outpatient clinics. According to publicly available data, there were 28 overdoses during pregnancy in 2020, the most recent year data in available. LDH is setting a goal to reduce overdose pregnancy deaths in the state by 80% over three years, reducing the death rate to five or six people annually. The department expects to appoint a Project MOM director within 90 days. Greenstein also announced the state would be moving away from having a single pharmacy benefit manager (PBM) for its Medicaid program. Such entities have been labeled as 'middlemen' that process prescription drug claims for the managed care organizations that provide Medicaid services, with critics saying they don't provide enough transparency to determine whether they provide any cost savings to patients. Since October 2021, Louisiana has worked with Magellan Medicaid Administration as its sole prescription benefit manager. On Monday, Maranto said the department would work closely with its managed care organizations who run the state's Medicaid program and pharmacies to 'ensure the best approach to managing these benefits.' The continued closures of chain and independent pharmacies threatens patient access to critical prescription drugs across Louisiana, Maranto added. The state's new approach will lean on the private contractors for Medicaid to handle prescription claims while also keeping drug prices in check. SUPPORT: YOU MAKE OUR WORK POSSIBLE
