JOHANNESBURG- The Government Employees Medical Aid Scheme (GEMS), which has recently been under scrutiny in the media for all the wrong reasons has come out in defense of its current financial situation after increasing calls from industry bodies to shut down the institution after allegations of mismanagement.
In an exclusive interview with Africa News 24-7 this week, the Principal Officer of GEMS, Guni Goolab has revealed that allegations that the institution is on the verge of bankruptcy is nothing but a fabrication aimed at destabilizing the entity’s obligation to its members who are government employees.
Allegations have been rife against GEMS in the media where various reports stated that the institution is not paying healthcare practitioners on time, driving many individuals operating in the healthcare space out of business.
This has led to more and more health professionals declining to accept GEMS, requesting members belonging to the scheme to rather pay cash upfront and then claim from the scheme at a later stage. Other allegations state that the scheme is engulfed in corruption that leaves members medical aids exhausted when they hadn’t even used their benefits.
In addition, Africa News 24-7 ran an investigation into how medical aid schemes in South Africa were systematically engaging in the racial profiling of black healthcare professionals when refusing to pay submitted medical claims, resulting in the financial ruin of the former driving healthcare practitioners to financial ruin and at times suicide.
Speaking to Africa News 24-7, Goolab said GEMS operates fully within the law, and medical aid fraud, waste and abuse investigations are no exception.
“Its very difficult to respond to certain allegations, especially when they have no merit, but you can be sure that GEMs is very healthy financially. GEMS operates under the medical schemes act and we provide a financial report on a quarterly basis to the council of medical schemes. No doubt in 2016 there was high hospital claims, but that was an industry-wide problem. We can meet all of our financial obligations,” he said.
Commenting on allegations of racial profiling, the Goolab said the company’s investigations are audit-based, and transparent and did not obtain information under false pretenses.
“At times, as part of the investigations, we do engage with scheme members to establish whether they have in fact received the services reflected on their medical claims statement. We also engage with the relevant healthcare practitioners after a meeting is agreed to. GEMS does not and will not target any specific group. When investigations are conducted, analytics are applied to the value and volume of claims to identify significant trends.
He added that the company did not dictate how many patients are treated in a day.
“Several health care services are time-based. GEMS take this into account for each discipline in arriving at an estimate of how many patients a healthcare practitioner could conceivably see per day, including operating hours and practice size. Under specific circumstances, for example where claims from a healthcare practitioner significantly exceeded the reasonable number of patients, it would be possible for them to see in a day, this would be identified as a potential outlier. We would then query this with the relevant practitioner as part of our due diligence in ensuring the validity of submitted claims. GEMS and its service providers utilize a multi-disciplinary investigative team, including where relevant registered medical professionals such as doctors, pharmacists, dentists, and nurses,” he said.