Guidance on Medical Aid Agreements
September 6, 2017

Kick Start 2017

Dear Professional
The issue of professional conduct and ethical behaviour is an ongoing concern to the HPCSA due to its impact, not just on practitioners, but also the healthcare sector and community at large. Council, and its Professional Boards, are aware of practitioner concerns surrounding acceptance of liability and refund agreements touted by medical schemes. To this end Council offers advice on access to clinical records, warns of practitioner prosecution for fraudulent activities, recovery of impropper benefits, the legal status of payment arrangements and the withholding of claims by medical schemes. Practitioners wishing further advice on ethico-legal matters can direct an email to this address.

Best wishes
The HPCSA Team

Access to clinical records
Schemes are entitled to access treatment records subject to the express consent of the beneficiary. Practitioners are advised to obtain written consent to disclose confidential information. Read more

Fraudulent activities
Council for Medical Schemes is obliged to refer improper conduct to the HPCSA. Those found guilty of unprofessional conduct involving fraud of more than R100 000 will be subjected to penalties and reported to SAPS. Read more

Recovery of ill-gotten benefits
In instances of theft, fraud, negligence or any misconduct, schemes may recover funds by deducting such amount from any benefit payable to the practitioner or through any other lawful arrangement made. Read more

Legal status of arrangements
The payment arrangements between practitioners and the scheme are legally binding if they are lawful. Medical schemes are oblidged to report unprofessional conduct to the HPCSA. Read more

Witholding practitioner claims
Schemes should pay within 30 days of receiving the claim, or furnish reasons for erroneous or unacceptable claims whereupon the claimant has sixty days to correct and resubmit. Read more