By Kirsty van Rhyn, Case Manager, Medical Protection

The hospital manager of a psychiatric facility was informed of an admitted patient who belonged to two different medical aids. The patient was admitted to the facility for psychiatric treatment and substance abuse rehabilitation; they claimed from one medical aid for payment of the psychiatric treatment and substance abuse rehabilitation from the other.

The hospital manager approached Medical Protection for advice, as he understood belonging to more than one medical aid was illegal. He wanted to know whether the patient’s claims from the respective funds amounted to fraud and whether there was a legal obligation for him to report the matter and, if so, to whom.

What we advised

Section 28 of the Medical Schemes Act 131 of 1998 does in fact prohibit the joining of more than one medical scheme. Section 66 of the same Act details the penalties for contravening any provisions of the Act. It also states that the contravention amounts to the person being guilty of an offence and liable on conviction of a fine or imprisonment not exceeding five years, or both a fine and imprisonment.

In terms of Section 34 of the Prevention and Combating of Corrupt Activities Act 12 of 2004, all people in a position of authority in both public and private sector is required to report corruption to the police if it involves R100,000 or more. Failure by people in positions of authority to report corruption is an offence and liable on conviction to a fine or to imprisonment. Section 34 further states who would be defined as a “person of authority”; such a person includes inter alia any person who is responsible for the overall management and control of the business of an employer, or any person who has been appointed as chief executive officer or an equivalent.

The HPCSA’s Booklet 2, Ethical and professional rules of the Health Professions of South Africa, was also authoritative in this matter. Rule 13 states that a practitioner shall only divulge information regarding a patient in terms of a statutory provision, at the instruction of a court of law, where justified in the public interest or in the absence of these requirements, with the express consent of the patient.

Based on the above points, we advised that should the amount claimed from the respective medical funds be equivalent to or exceed R100,000, the matter would have to be reported to the South African police service as the member’s representative would be viewed as a person of authority and thus have an obligation in terms of a statutory provision to report the patient. If, however, the amount claimed was less than R100,000, the obligation to report the matter to SAPS in terms of Section 34 would not apply.

The member was advised that belonging to two medical aids, however, is still in contravention of Section 28 of the Medical Schemes Act, although there is no obligation imposed on the hospital manager to report the matter in terms of this section. It was suggested that the hospital manager arrange a meeting with the patient and obtain consent to disclose the information to the respective medical aid funds or allow the patient the opportunity to disclose the matter himself, as the patient would need to provide written consent in terms of Rule 13 of the HPCSA guidelines. We advised that the consent be obtained by the manager voicing his concerns to the patient, together with explaining the relevant laws and the consequences of not following them.

Outcome

The hospital manager confirmed that the claims were not in excess of R100,000. Acting on our advice, he consulted with the patient and informed him that it is not permissible to be a member of two different medical funds and informed him of his intent to disclose this fact to the respective medical funds.

Learning points

•            Section 28 of the Medical Schemes Act 131 of 1998 prohibits the joining of more than one medical scheme.

•            Section 34 of the Prevention and Combating of Corrupt Activities Act 12 of 2004 creates an obligation that all people in a position of authority in both public and private sector are required to report corruption (fraud) to the police if it involves an amount of R100,000 or more.

•            Rule 13 of HPCSA’s Booklet 2 states that in the absence of an obligation to report a matter in terms of a statutory provision, a court order or in the public interest, all disclosures of patient information must be done with the express consent of the patient.

•            If a practitioner has knowledge or suspects fraud, in any manner whatsoever, and is unsure whether they should report or not, it is crucial that Medical Protection be contacted as soon as possible to assist.

•            The member’s first obligation remains to their patient.