Discovery defends clawing back money from doctors after 'irregular billing'

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Discovery Health says it has been clawing back monies from medical providers because of "irregular billing". (Boogertman and Partners)
Discovery Health says it has been clawing back monies from medical providers because of "irregular billing". (Boogertman and Partners)
  • Discovery Health says it has been clawing back monies from medical providers because of "irregular billing".
  • The company says it has been detecting these either through tip-offs or trends or information that emerges after the claim has been paid.
  • It says medical schemes would lose billions of Rands each year if they don't claw back these monies.


Discovery Health says it has been clawing back money from doctors following "irregular billing" - to protect its medical aid members.

The medical schemes administrator came under fire this week for allegedly claiming back monies it had paid to healthcare providers years ago - when medical schemes are supposed to address any disputed claims within 30 to 60 days of receiving them.

Irregular billing occurs when medical providers charge more than what the agreed billing rules allow, or when there are purely fraudulent claims.

Discovery health said irregular billion represents 6% to 8% of total claims paid by the scheme .

"These recoveries are by definition not identifiable as irregular claims at the time of payment and are detected either through tip-offs or trends, or information that emerges after the claim has been paid," said Discovery Health.

Accordingly, the company said there is no 30-day requirement to recover funds paid to irregular claims. Funds recovered from these clawbacks go back to members' medical aid reserves or into their medical savings accounts if they weren't paid from the scheme's risk pool.

Discovery Health has faced scrutiny after a panel appointed by the Council for Medical Schemes and chaired by advocate Tembeka Ngcukaitobi found that the company unfairly discriminated against black doctors.

The panel found outcomes of fraud, waste and abuse investigations conducted by Discovery, GEMS and Medscheme between 2012 and 2019, "amount to unfair racial discrimination against black practitioners"

READ | Interim report finds GEMS, Discovery and Medscheme guilty of 'unfair discrimination' against black doctors

In a statement issued on Tuesday evening, Discovery Health said medical schemes have a duty to protect their members' funds and have the right under the Medical Schemes Act to recover or claw back monies already been paid to medical providers where they have "positively identified that irregular billing has occurred". 

Discovery Health added that the forensic processes it follows to probe suspected irregular claims were critical for the sustainability and affordability of medical aid. And if it doesn't recover funds from erroneously billed claims, this could threaten the survival of schemes it administers in the long run. The company estimated that the industry would lose at least R1.7 billion of member's medical aid money to fraudulent claims per year if it does not curb billing abuse.

The company said it pays providers after seven days of receiving a claim on average. But it sometimes delays payment when it wants to accumulate additional information on the claim submitted to reduce the number of clawbacks. The company said it recognises that this delay could be detrimental to medical providers, the vast majority of whom bill correctly and reliably.

"Much like corruption and theft, medical schemes cannot tolerate fraud, waste and abuse of billing rules by healthcare providers," wrote Discovery Health in the statement.

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