The processes used by medical schemes to carry out forensic audits on physiotherapists are unfair, suggests a recent study, which revealed troubling ethical and procedural gaps, according to the authors, and which calls for urgent reform.
The University of Pretoria research found that practices intended to prevent billing irregularities often leave practitioners fearful, stigmatised and traumatised without proving guilt.
The research, led by Lesley Meyer, an extra-ordinary lecturer in the Department of Physiotherapy, explored the lived experiences of physiotherapists who have undergone such audits, finding that these often extend beyond their legal scope and adversely affect the profession. Additionally, the audits often pocket patients’ savings instead of returning them to the patients, in accordance with the Medical Schemes Act.
The study was published in the South African Journal of Physiotherapy.
“Participants reported feeling unfairly targeted and singled out, describing the audit process as unfairly conducted. Many felt they were subjected to a witch hunt,” said Meyer, who is also a physiotherapist and runs a private outpatient practice with a special interest in chronic pain and trauma management.
The authors wrote that practitioners were sometimes accused of overbilling or coding errors without being given access to the evidence used against them.
Some described being pressured to sign an Admission of Debt (AOD) to avoid escalation, leading to payments that varied from R54 000 in a solo practice to R4.5m for one group practice.
The authors said compounding these audits were the outdated tariffs available for billing in South Africa. The gazetted tariff codes have not been updated by the Competition Commission since 2006, because of restrictions by the commission on “cohesive” billing practices, and medical schemes do not accept new un-gazetted tariff codes.
So practitioners may be forced to use outdated codes to describe new evidence-based treatment modalities or not bill for these modalities at all.
The authors called for urgent systemic reform in audit practices, billing codes, legal protections and emotional support, saying that professional bodies and government institutions must ensure audits are conducted fairly, following the law and grounded in principles of care and justice.
Physiotherapists must be supported to reduce attrition and mitigate the negative repercussions of forensic audits, which adversely affect the profession, added Meyer.
Study details
Experiences of physiotherapists audited by South African medical funding schemes
Lesley Meyer, Werdie van Staden, Karien Mostert.
Published in SA Journal of Physiotherapy on 13 February 2026
Abstract
Background
Forensic auditing safeguards patients’ funds by investigating billing irregularities of claims submitted to medical schemes. However, billing irregularity audits can be misguided, as indicated in a study conducted in Australia, Canada and the United States. Negative consequences were reported, including attrition, and patients funding their treatments out of pocket. Medical professionals were penalised, without forensic auditors considering alternative explanations for the alleged irregular billing patterns. Small medical practitioners, unable to defend themselves financially, closed their practices, leaving patients without medical care. In South Africa, the experiences of physiotherapists who underwent forensic audits have not been examined.
Objectives
This study explored physiotherapists’ experiences of forensic auditing by medical scheme administrators.
Method
An analytical qualitative study was conducted to interview 14 physiotherapists. Three focus group discussions and 11 individual interviews were conducted. A semi-structured open-ended interview guide was used, analysing the data via open and axial coding.
Results
The first five themes that emerged captured the adverse experiences of physiotherapists. These were (1) ‘unfairly persecuted, judged and penalised’; (2) ‘overpowered and oppressed’; (3) ‘naively entrapped between a rock and a hard place’; (4) ‘distressed with a knife over your head’ and (5) ‘detrimental and hurtful’. In the sixth theme, ‘seeking remedies pre-emptively and preparedly’, the participants made recommendations to prevent similar unwanted experiences.
Conclusion
Physiotherapists experienced significant emotional, financial and professional detriment at the hands of South African medical scheme administrators.
Clinical Implications
The quality of care provided by physiotherapists is adversely affected when forensic audit-related distress occurs.
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