An independent investigation has absolved Mediclinic Southern Africa of billing fraud allegations, the private hospital group announced yesterday.
Mediclinic initiated the probe in August last year, appointing law firm ENSafrica to conduct a forensic investigation into anonymous claims of billing irregularities at six hospitals in Gauteng and the Western Cape.
The whistleblower alleged manipulation of ICD-10 codes on patients’ bills to inflate claims submitted to medical schemes.
Read: CMS calls for comprehensive investigation into Mediclinic billing fraud allegations
Mediclinic said the investigation refuted these claims, stating that the investigation found no intentional manipulation of billing or coding at either hospital or group levels. Moreover, no evidence reflected a culture of victimisation within the group.
Steven Powell, the head of ENSafrica’s forensics practice, said Mediclinic provided the firm with unrestricted access to investigate the allegations made against the named hospitals, along with an additional six hospitals randomly selected by ENSafrica. The investigation included interviews with Mediclinic staff and a review of more than 120 000 emails and documents.
According to Mediclinic, the investigation found no evidence of deliberate manipulation of patients’ bills. Additionally, there were no incentives or direct financial benefits encouraging such practices among Mediclinic staff.
Powell said although the investigation identified some incidents involving mistakes or unintended errors, these were “random and minuscule”, constituting part of the normal course of business.
One previous billing problem led to a disciplinary process for an employee.
The whistleblower’s allegations centred on the alternative reimbursement model (ARM), where medical schemes pay a fixed amount for specific medical care or treatment of a particular disease. The allegations suggested that employees manipulated coding to mitigate losses under the ARM deal.
Powell said that such incidents occurred mainly during the initial implementation of the ARM agreement in 2011, particularly at a hospital recently added to the group.
He acknowledged that mistakes with ARM still occurred, but their volume was relatively low compared to the overall transactions. Medical funders told the investigation that errors were not uncommon in such transactions.
Greg van Wyk, the chief executive of Mediclinic Southern Africa, said the group serves more than 500 000 patients a year. He said that while errors are inevitable, Mediclinic engages regularly with medical schemes to address and rectify any mistakes, considering them as part of the normal operational challenges within the healthcare industry.
