6.2.1 The main research question
6.2.1.1 What is the degree of ethicality of South African Medical Schemes with regard to fraud investigation and management amongst medical practitioners as stakeholders?
In answering the main research question, the hypotheses formulated in Chapter One are revisited (see Chapter One, Section 1.8).
It was hypothesised that Medical Schemes are not ethical with regard to the management of medical practitioner fraud, because:
Medical schemes‟ alleged response to uncovered fraud is not consistent with that reported by medical practitioners
The rational decision making frame of Medical Schemes is not of an ethical nature
Medical Schemes do not comply with the principles of good governance
The actions of Medical Schemes in response to uncovered fraud is not ethical
There is no decisive governing body to regulate dispute resolution in the industry and no common Alternative Dispute Resolution framework
The null hypotheses stating that in the experiences of medical practitioners, Medical Schemes‟ fraud management is not unethical (H01) and; the investigation tactics of medical schemes is not unethical (H05) are excluded from the conclusions and recommendations since the measuring instruments of these two independent variables were found to be invalid during the analysis of the results in Chapter Five (see Section 5.3, Table 5.6).
The second null (H02) and alternative hypotheses (H2) were as follows:
H02: Medical Schemes‟ alleged response to uncovered fraud is consistent with that reported by medical practitioners
H2: Medical Schemes‟ alleged response to uncovered fraud is inconsistent with that reported by medical practitioners
The empirical results demonstrate that the respondents generally agree with the Medical Schemes Administrators responses reported in the 2010 KPMG survey (see Chapter Five, Section 5.3.1). The null hypothesis (H02) can therefore not be refuted and this means that there is consistency with what Medical Schemes administrators reported their response to uncovered fraud is and what medical practitioners generally observe it to be.
The third null (H03) and alternative hypotheses were;
H03: Medical schemes‟ rational decision making with regard to fraud investigation and management is not unethical
H3: Medical schemes‟ rational decision making with regard to fraud investigation and management is unethical
The empirical results show that the majority of the responses are negative in terms of the ethicality of the rational decision making of Medical Schemes (see Chapter 5, Section 5.3.2). In terms of these results the null hypothesis (H03) is refuted and the alternative hypothesis (H3) supported. This means that the rational decision making of Medical Schemes is perceived as unethical and that Medical Schemes managers should take greater heed of the morality of their decisions.
It is acknowledged that the actions that serve the greatest good of the greatest number of people affected by it, that treats all stakeholders with respect and integrity and that is in line with the actions of a “virtuous” person, would provide tremendous moral conviction in any situation. The ideal is surely that all leaders behave in this manner. It is also important for leaders to take note of the fact that mere compliance with the law does not imply that an action is the most ethical, since laws themselves are formulated in accordance with virtuous behavior, i.e. justified by concerns about the greatest good for the greatest number of people. Leaders and mangers should therefore not merely base their decisions on what is stated by legislation.
The fourth null hypothesis (H04) and alternative hypothesis (H4) were;
H04: Medical schemes adhere to the four ethical values that underpin good corporate governance
H4: Medical schemes do not adhere to the four ethical values that underpin good corporate governance
The empirical results indicate that the majority of respondents had a negative perception of the governance value structure of Medical Schemes (see Chapter 5, Section 5.3.3). In terms of these results the null hypothesis (H04) is refuted and the alternative hypothesis (H4) supported.
In Chapter 3, Section 3.4 it was stated that “corporate governance and business ethics have always been ambiguous”, questioning whether corporate governance has an ethical nature or whether it is merely selfish. It appears that Medical Schemes leaders could strive to show a greater commitment to organisational integrity in terms of their fraud investigations of medical practitioners as stakeholders, through upholding fairness, transparency, honesty, non-discrimination, accountability, responsibility and respect for human dignity, human rights.
The sixth null hypothesis (H06) and alternative hypothesis (H6) were;
H06: The actions of Medical Schemes in response to fraudulent medical practitioners are not unethical
H6: The actions of Medical Schemes in response to fraudulent medical practitioners are unethical
The empirical results indicate that most of the respondents scored the fraud management actions of medical schemes negatively in terms of ethicality (see Chapter 5, Section 5.3.4). The null hypothesis (H06) is therefore refuted and the alternative hypothesis supported. It should be noted that there was a significant degree of uncertain surrounding most of the responses and that significant variation exists amongst different schemes policies with regard to the treatment of fraudulent practitioners.
Medical Schemes policies regarding the treatment of fraud perpetrators could perhaps be more consistent. The Medical Schemes Anti-Fraud Surveys conducted by KPMG since 2001, indicate that schemes treat fraudulent practitioners at their own discretion with no consist standard procedure adhered to.
6.2.2 The secondary research questions
Addressing the primary research objective; the development of a protocol for the ethical investigation and management of Medical Schemes fraud by medical practitioners in South Africa, the following secondary research questions were answered.
6.2.2.1 What is the role and scope of the medical schemes industry in South Africa and the extent of fraud?
This research question was answered in Chapter Two, where a detailed literature review and discussion was provided on the role, relevance and fraud challenges of the Medical Schemes industry in South Africa.
6.2.2.2 What is the importance of business ethics in the context of stakeholder and issue management?
Chapter three provided an answer to this research question by means of a literature review on business ethics, in particular a stakeholder and issue management approach.
6.2.2.3 How can a research methodology be formulated in order to understand and reproduce this research study in future?
Chapter four provided a discussion on the research design and methodology that was used for the empirical study.
6.2.2.4 What is the current fraud investigation and management practices of medical schemes?
Chapter five provided an analysis, interpretation and discussion of the results of the empirical study.