Section 59 Investigation

Healthcare providers, represented by two associations, made public allegations about their treatment by medical schemes and administrators. They alleged that medical schemes and administrators were:

• • Racially profiling providers for investigation;
  • Applying invasive investigation methods;
  • Bullying and coercing providers to sign Acknowledgement of Debts (AoD);
  • Unfairly placing providers on indirect payment;
  • Unlawfully blacklisting healthcare service providers; and
  • Applying self-help tactics relying on section 59 of the Medical Schemes Act, (131 of 1998) (MSA).

The said complaints and allegations were also informed by how the medical schemes and administrators interpreted and applied the provisions of Sections 59 (2)(3) of the MSA and its related regulations.

The CMS commissioned an investigation on the above allegations which entailed:

• Establishing a panel in June 2019, under the auspices of Section 7, 8 and 9 of the MSA led by Advocate Tembeka Ngcukaitobi SC, assisted by Advocates Adila Hassim and Kerry Williams.
• Consulting with all industry stakeholders, the CMS, in its capacity as Regulator of the medical schemes industry, and
• Contracting the services of an independent panel of experts with the view to investigate the allegations.

As expected, the Panel commenced with its inquiry which comprised of two main issues namely:

• Racial discrimination by schemes against black health care providers; and
• Procedural fairness of the treatment of black health care service providers.

While the enquiry may have comprised of the above main issues the scope of the investigation extended to assessing fraud, waste and abuse (FWA) to the extent that these were possible defences which were advanced by the medical schemes and administrators respectively.

As expected, the Panel considered, and reviewed the submissions and evidence of all stakeholders which culminated in the compilation of a draft interim report.