It is important to note that the findings of this study should be viewed in light of certain limitations.
One of the possible limitations of the study was the small sample size. The sample size (n=50) is considered low for a positivistic study. In addition, time constraints did not allow for a more representative sample in terms of the demographic profile of the sample population. A more balanced demographic profile in terms of location and practising field or speciality would have been more feasible.
A qualitative study for a more detailed exploration of the current industry practices and experiences could provide a better description of problematic areas and the identification of the best solutions for the shortcomings of the current system.
6.5 CONCLUSION
This chapter presented an answer to the main research question by presenting an interpretation and discussion of the empirical results of the research study. Included in this chapter are the answers to the five sub research questions, a final evaluation of the research methodology, the limitations of the study and recommendations and further research.
The cost of unethical business conduct clearly outweighs the competitive advantage that could be gained from ethical business conduct. There has been a paradigm shift in terms of stakeholder management, with inclusive stakeholder models thought to add greater value.
Implementing the recommendations discussed in section 6.3 above could go a long way in securing integrative solutions to the main research problem; namely the fact that no standard fraud investigation and management protocol exists in the private healthcare sector. The stakeholder approach could be an effective communication strategy to change the “rules of engagement” amongst medical schemes and medical service providers to create win-win outcomes.
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ANNEXURE A QUESTIONNAIRE COVERING LETTER
Dear Respondent
I am a post-graduate student studying towards my MBA (Masters in Business Administration) degree at the Nelson Mandela Metropolitan University Business School. I am conducting research on how to ethically conduct investigations into medical service providers, suspected of fraudulent behavior. I believe that my study will make an important contribution to the improvement of stakeholder relationships in the Medical Schemes industry in South Africa.
You are part of our selected sample of respondents whose views we seek on the above-mentioned matter. We would therefore appreciate it if you could answer a few questions. It should not take more than fifteen minutes of your time and we want to thank you in advance for your co-operation.
There are no correct or incorrect answers. Please answer the questions as accurately as possible. For each statement, tick the number which best describes your experience or perception. For example, if you strongly agree with the statement, tick the number 5. If you strongly disagree with the statement, tick the number 1. Tick only one answer for each statement and answer all questions please.
Please note also that your participation in this study is entirely voluntary and that you have the right to withdraw from the study at any stage.
Thank you very much.
Phyllis Titus
To verify the authenticity of the study, please contact Celestin Ndhlovu at 041 4032437 and [email protected]
ANNEXURE B THE MEASURING INSTRUMENTS
SYSTEMATIC RATIONAL ETHICAL DECISION-MAKING FRAMEWORK
Medical Schemes justify their actions, according to whether their actions are beneficial to them.
Medical Schemes justify their actions according to whether their actions are supported by their industry peers
Medical Schemes justify their actions according to whether these actions are supported by national laws
Medical Schemes justify their actions according to whether their actions are for the greatest good of the greatest number of people
Medical Schemes justify their actions according to whether their actions treat every stakeholder with respect and dignity
The fraud investigation practices of Medical Schemes are in line with that of an honourable person/entity
KING REPORT PRINCIPLES OF GOOD GOVERNANCE
Medical Schemes fraud investigation methods are justified and fair, since they are merely recovering their losses from suspect Medical Practitioners
Medical Schemes are held accountable for their actions pertaining to their investigations of suspect Medical Practitioners
The fraud investigations into suspect Medical Practitioners are done in a responsible manner.
INVESTIGATION TACTICS OF MEDICAL SCHEMES
Medical Schemes bully Medical Practitioners due to the relevant small size of their business or practices
Medical scheme „engaging‟ with suspect practitioners during “compulsory” mediation meetings represent extortion or duress rather than legitimate commercial interactions
Medical Schemes fraud investigation methods and management is fair and ethical
The informant or whistle-blower approach to exposing fraudulent Medical Practitioners is ethical
Testing allegations (referred to as undercover probing) is an ethically acceptable method of uncovering fraud amongst Medical Practitioners
Entrapment (setting up) of Medical Practitioners is an ethically acceptable method of uncovering fraud
ACTIONS OF MEDICAL SCHEMES IN RESPONSE TO FRAUD
Medical Schemes sharing information about fraudulent Medical Practitioners through the BHF Forensic Management Unit is ethically acceptable
Medical Schemes reporting fraudulent Medical Practitioners to applicable Governing bodies are ethically acceptable
Medical Schemes instituting civil action against Medical Practitioners for monetary recovery of fraudulent claims are ethically acceptable.
Medical Schemes blacklisting uncovered fraudulent Medical Practitioners is ethically acceptable
Medical Schemes negotiating with uncovered fraudulent Medical Practitioners for settlement or recovery of losses are ethically acceptable
Medical Schemes stopping direct payment to uncovered fraudulent Medical Practitioners is ethically acceptable
Medical Schemes keeping uncovered fraud quiet is ethically acceptable
Medical Schemes reporting uncovered fraudulent activity to the South African Police Service (SAPS) is ethically acceptable
MEDICAL SCHEMES REPORTED RESPONSE TO UNCOVERED FRAUD To keep it quiet
To report it to the applicable governing body, e.g. HPCSA, BHF To report it to the South African Police Service (SAPS)
To institute civil action against Medical Practitioners for recovery
To blacklist Medical Practitioners
To share information with other Medical Schemes through the BHF Forensic Management Unit
To negotiate settlements with providers to recover losses
To stop direct payment to Medical Practitioners or Service Providers
STAKEHOLDER DISPUTE RESOLUTION METHODS
Investigations into suspect Medical Practitioners should be conducted by
Interactions between Medical Schemes and Medical Practitioners pertaining to suspected fraud should be convened by
Dispute resolution between Medical Schemes and Medical Practitioners regarding suspect claims submitted should be in the form of