The SA Private Practitioners Forum, representing doctors, says medical schemes, which analyse claims data to identify outliers, do not always appreciate that there might be legitimate reasons for a specialist whose billing pattern is out of the ordinary.

It has no evidence, however, that medical schemes are using racial profiling to determine which of its members to investigate for fraud, reports Business Day.

The Council for Medical Schemes (CMS) is conducting an investigation into allegations from the National Healthcare Practitioners Association that medical schemes and administrators are targeting black and Indian doctors for fraud investigations and unfairly withholding payments. The CMS regulates the medical schemes industry, and is conducting its second round of public hearings into the matter this week.

Commenting on billing patterns, Forum president Adri Kok said, for example, a doctor who had developed an interest in a specific area of medicine, such as cardiology, might bill for more heart-related events than the average.

Similarly, doctors who worked in isolated areas with few doctors were likely to have higher hospital admission rates than their urban counterparts.

Kok said the forum had been able to help many of its members resolve their disagreements with medical schemes, and urged doctors to co-operate when asked to open their books.

Some doctors, she said, particularly the more junior ones, billed incorrectly out of ignorance rather than because they intended to commit fraud.

But she conceded there were doctors who deliberately sought to defraud medical schemes.

“Some outliers are indeed frauds,” Kok said, citing a doctor who had abused the coding system to bill for R2.5m in services he had not provided.

- See a full report on the hearings in today's Business Day newspaper