A Durban-based surgeon is taking on South Africa’s largest medical scheme — Discovery Health, accusing it of racial profiling, an accusation the group has challenged and rejected outright.

Dr Aslam Noorbhai, director of Umhlanga based ScopeCare, a private surgical practice, is also preparing to challenge Discovery in court after the scheme said it would no longer authorise him as a service provider for their clients — effectively excluding half of his patients from referral. Noorbhai insists he is being targeted for speaking out against what he calls “racial profiling” by Discovery.

“Patients who are friends or relatives with Discovery’s directors get treated preferentially better than any other patient,“ Dr Noobhai told IOL. ”Discovery also purposely delay much needed cancer treatments like immunotherapy, because they wait for patients to be upstaged, at which point, the patient is either too ill for treatment or dies. If it is for a patient aligned to Discovery hierarchy, the same treatments are approved and expedited.

“Other doctors keep quiet because Discovery pays those other specialists an amount for every discharge summary that they send to Discovery. This is equivalent to perverse incentives which is not allowed in medicine. I refuse to have my practice contracted to Discovery because they will tell you what meds, instruments in theatre, and other medical devices to use for patients, based solely on costs. Treatment for patients is based on how much that patient pays them, not what the patient actually requires. I feel I am being targeted because I refuse to be silent and because I am Muslim,” Dr Noorbhai said.

But, Discovery has flatly rejected the accusations. The group says it’s uncovered several discrepancies on payment submissions by Dr Noorbhai, prompting it to stop payouts to him.

“Discovery Health’s forensics department has been conducting a forensic investigation into Dr Noorbhai’s practice since May 2, 2024. This was prompted by complaints made about Dr Noorbhai’s practice related to obtaining pre-authorisation for procedures performed by him. As part of its fiduciary and ethical obligations, Discovery Health thoroughly investigates all complaints brought to its attention,” Discovery Health CEO Dr Ron Whelan told IOL in response.

“During the course of the forensic investigation into Dr Noorbhai’s practice, Discovery Health formally requested Dr Noorbhai to submit specific records to verify that the monies which had been paid to him by the medical schemes administered by Discovery Health were for valid claims and services rendered. Regrettably, despite repeated requests and follow-ups over a period of more than seven weeks, Dr Noorbhai failed to provide the necessary information to verify that the claims for services rendered to members of the medical schemes were valid.

“Due to Dr Noorbhai’s failure to provide the requested supporting information and documentation, Discovery Health was left with no option but to suspend further reimbursement for claims submitted by Dr Noorbhai’s practice as of September 5, 2024, until further notice. This decision was duly communicated to Dr Noorbhai, the hospital group involved and the patients treated by Dr Noorbhai during the preceding 12 months.

“Subsequent to the communication of this decision, Dr Noorbhai provided the information requested by Discovery Health’s forensics team. Unfortunately, this information from Dr Noorbhai’s practice confirms that there are discrepancies in the billing of certain procedures.  Discovery Health’s forensics team therefore continues to engage Dr Noorbhai on this matter and the investigation remains ongoing,” Dr Whelan said.

The group insists it has not received any legal papers and is ready to challenge what is calls “baseless” accusations.

But, several patients have come forward in defence of Dr Noorbhai.

“I’ve had several procedures with another surgeon and it is only when I went to Dr Noorbhai that the problem was diagnosed. This also saved Discovery Health money because it meant I did not have to keep being operated on. Despite this, Discovery still did not pay Dr Noorbhai the full amount. They keep asking him for motivations which I don’t understand,” Glenda Naicker whose family has been with Discovery Health, explained.

Dr Noorbhai has also hit back, questioning Discovery’s reasoning.

“They impose letters of motivation as a delaying tactic so that they do not have to pay out,” Dr Noorbhai said. “Once the four months are past, they do not pay, neither will gap cover pay due to elapsed time. It’s a purposeful and deliberate act of delaying payouts to non-contracted specialists. Even when the letters of motivation are provided, they do not provide feedback or even read them, if they come from non-contracted specialists,” added Noorbhai.

But, Discovery insists it upholds the highest standards of ethical practices and is bound by its due diligence when paying service providers.

“Discovery Health is committed to ensuring that members of its administered schemes have uninterrupted access to care if the practice of their preferred provider may have been suspended. In the case in question, Discovery Health informed this particular member on September 2, 2024 that Dr Noorbhai’s practice had been suspended from further reimbursement due to an ongoing investigation,” Dr Whelan told IOL.

“When the member enquired in mid-October 2024 about an upcoming surgery, they were advised that the procedure would be funded by Discovery Health Medical Scheme if the procedure was conducted by a surgeon in continued good-standing with the medical scheme.

“Discovery Health upholds a zero-tolerance policy towards fraud, dishonesty, and misrepresentation. Discovery Health has full confidence in the integrity and rigour of its claims processes, as well as the appeals mechanisms, to ensure that all valid claims are honoured and any potential errors are addressed. Dishonest and fraudulent practices jeopardise the financial sustainability of the medical scheme, which depends on member contributions to meet their long-term healthcare needs,” added Whelan.

IOL

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