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Medical schemes don't cater for physicians outside cities, inquiry told

The SAPPF presented evidence at the section 59 inquiry in Centurion, which was looking into allegations of racial profiling in the medical profession.

Picture: Supplied.

PRETORIA - The South African Private Practitioners' Forum (SAPPF) said the medical schemes coding system used in the country was at the centre of what appeared to be harassment of health practitioners.

The SAPPF presented evidence at the Section 59 inquiry in Centurion on Tuesday, which was looking into allegations of racial profiling in the medical profession.

The forum’s Dr Adri Kok said doctors outside cities suffered the most because the schemes didn’t understand the conditions under which they operated.

The SAPPF said a quarter of its 250 members who were investigated by medical aid schemes were black and Indian, compared to less than 5% who were white.

But Dr Kok said the challenge was that schemes didn’t understand the conditions of physicians outside cities.

“For example, if you have a doctor working in Vryburg in the North West, there is only one physician almost in a 20km radius. They would receive all the patients, so if you look at admissions to hospital, they would appear to be an out layer because of their geographic location rather then that they are abusing the system,” she said.

She said the country should develop its own coding system.

“We have often asked that there should be a South African development to assess the local situation. You can’t use a Johns Hopkins model in South Africa,” Kok said.

The SAPPF said it had successfully mediated on behalf of doctors who were investigated.

PATIENT'S PRIVACY

Specialist medical practitioners said some medical aid schemes that suspect fraud in their claims don’t understand what they do.

The SAPPF said it could not say with certainty that schemes targeted black and Indian doctors, but its data showed that they make up a quarter of investigations.

Dr Kok was one of many practitioners who have been investigated by medical schemes.

She said if a specialist was suspected of fraud, another specialist should make the final assessment and not a general practitioner.

“Who approaches you? A management person, not a doctor. She looked at the files and saw the patients’ details, so clearly, there’s no privacy for my clients but they say they have the right to that. It’s a difficult thing and I can’t refuse because they will say I’m being obstructive.”

Kok said in some cases, funders didn't know what a specialist physician did and in her opinion where doctors don't comply their association should be the final arbiter.

“If the doctor doesn’t comply, there is HSPCA (Health Professions Council of South Africa) because we cannot afford fraud.”

Like other practitioners who have come before the inquiry, specialists too said they were forced to disclose confidential patient information to investigators.

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