Huh? Medaid body facing fraud probe hosts anti-fraud summit

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Huh? Medaid body facing fraud probe hosts anti-fraud summit

The medical aid regulator does not, however, see any irony in hosting the event

Journalist


The Council for Medical Schemes (CMS) says there is no irony in hosting a two-day summit on fraud in the medical industry when the body itself is under investigation by the Special Investigating Unit (SIU) for alleged corruption.
The CMS is the state regulator of medical aids.
The head of its investigations unit, Stephen Mmatli, was suspended earlier this month on full pay following a whistleblower’s tip-off that investigations into medical aids may have been squashed in exchange for bribes.
Registrar of the body Dr Sipho Kabane said he rejected claims that the body couldn’t host a fraud summit starting on Thursday in Sandton even though the SIU was probing it.
He said the CMS itself asked the SIU to investigate. “The statement that the CMS is in trouble is an interpretation of facts I don’t agree with. The facts are whistleblowers gave management a tip-off at CMS alleging a manager [was corrupt]. We have done everything to address that matter.
“We have suspended the individual concerned. We are starting an investigation. We were gracious enough to talk to stakeholders. They didn’t hear this from other sources but from us. We did not hide it.”
When Mmatli was suspended, Kabane wrote: “We received an anonymous tip-offs alleging ... that Mr Mmatli has been involved in corrupt relationships with organisations regulated by the CMS [medical aids]. Secondly, that he has deliberately misled the council to take decisions in favour of those organisations and benefited financially in return.”
Kabane told the media the SIU’s initial investigations into the CMS had implicated other organisations in the medical sector.
“This problem is not confined to the Council for Medical Schemes.”
The head of the special investigating unit, Advocate Andy Mothibi, speaking in Sandton, said its interviews with whistleblowers showed “irregularities” within the Council for Medical Schemes and organisations in the private health sector.
When Kabane was asked about the fact the regulator had invited a doctors’ group to speak on fraud at its conference, even when this group was also implicated in multiple instances of fraud detailed in court papers, he said: “This is not a gathering of the pure white. We are gathering because we want to achieve something against fraud waste and abuse.”
He said if the media knew more about the stakeholders involved and thought “they were pure and white, I think you ... would be very disappointed”.
The Sunday Times reported on the court matter involving the National Healthcare Professionals Association last year.
Currently, there are also CMS investigations into Discovery and Gems, the two biggest medical aids in the industry. The investigation into Bonitas has allegedly stalled, Business Day reports. Kabane would give neither updates nor explanations for the investigations, and said “it was business as usual” and the regulator’s findings would remain confidential.
“When the CMS inspects an entity, the report remains a confidential document.”
He also said the media was curious about various investigations, but the forensic reports would never be given. “We will not give them to you.”
The CMS fraud, waste and abuse conference this week is also addressing “abuse” in the industry, which can mean the incorrect use of medical funds or medical aids refusing to pay for legally required treatment. Yet the council has stopped publishing appeal rulings against medical aids, which help patients learn when they have a case to argue.
Medical lawyer Elsabe Klinck said it was a “big problem” that findings were not published.
Rare Disease patient advocate Kelly du Plessis also said the findings should “absolutely” be published.
Kabane, who has been acting registrar for the past two years, said he had “recently” learned the CMS had stopped publishing the appeal findings “for some reason”.
It would start doing so again. “It is an important service to members to see if a member has a legitimate case or not if they lay a complaint.”

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