South Africa: Medical Practitioners Lambast Discovery Health for 'Unethical, Irregular' Clawbacks


Medical practitioners are up in arms, saying the scheme is forcing them to hand over clinical notes and intimidating them into paying debt that has long prescribed.

Discovery Health has come under fire from medical practitioners for unethically "clawing back" claims it had approved and paid, well past even the three-year common law prescription period.

A medical aid fund must, in accordance with the Medical Schemes Act (MSA), query or dispute a claim within 30 days from the date of lodging, by providing written notice to both the fund member and the healthcare provider. The latter then has 60 days within which to respond and rectify the claim. If the scheme does not notify either party within 30 days that a claim is erroneous, or fails to allow correction and resubmission, the onus is on the scheme to prove the error.

This is a statutory time limit that extinguishes the right to, at a later stage, revisit the issue afresh, contest and claim back payment.

Discovery has exceeded these time limits, by far. Some treatments were pre-authorised, accepted and paid after the procedure, while others were authorised and paid once the procedure was performed.


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