An independent investigation has cleared Mediclinic of intentionally manipulating billing, after allegations – by someone claiming to be a former Mediclinic employee – were emailed to more than 50 principal officers of SA’s biggest medical schemes.
Although the probe uncovered some mistakes and unintended errors, it said these were “random and miniscule”, reports News24.
The hospital group had originally been accused of intentionally manipulating billing or coding to save money, but Steven Powell, head of law firm ENSafrica’s forensics practice, said he found no evidence of this.
The few incidents involving mistakes or unintended errors were “miniscule”, and formed part of the “normal cause of business”.
One previous billing problem had led to a disciplinary process for an employee, he told News24.
“The processes we investigated are complex, and we found no evidence of an intentional practice of manipulating billing or coding at a group or hospital level. This is supported by the existence of multiple checks and balances on billing practices.”
The initial “whistle-blower” email contained detailed information about what the person claimed to be their experience as a former clinical case manager at six Mediclinic hospitals. In addition, a former Mediclinic employee contacted News24 with similar claims at two hospitals.
Powell said the probe focused on the six hospitals, and then six other hospitals in the group were randomly selected without forewarning. Relevant staff were interviewed, records were observed, and around 121 000 emails analysed.
Part of the allegations focused on the alternative reimbursement model (ARM). Medical schemes often enter into an agreement with a hospital to pay a fixed amount for specific medical care or treat a specific disease.
The alternative would be that they would have to pay for every service rendered.
Medical schemes often prefer the ARM option, because they believe this may discourage hospitals from providing unnecessary services.
The whistle-blower alleged that when Mediclinic faced a loss under the ARM deal, some employees would manipulate the coding of the cases to save the hospital group money.
But Powell said the incident referred to was in 2011 when the ARM agreement model was initially implemented, and when that particular hospital was a recent addition to the group.
“They didn’t adapt well to the changes, and made mistakes. It was investigated properly (at the time), and the finding was that it was unfortunate. But the mistakes were addressed. Meetings were held, and training interventions took place.”
Powell said that mistakes with ARM still occurred, but “the volume of mistakes is low in comparison to the volume of transactions”.
Mediclinic Southern Africa CEO Greg van Wyk said the group sees more than 500 000 patients annually, and that the industry “recognises that errors do take place and ours are within those parameters”.
“Some of those errors can be to our detriment…with the medical aids, we engage on a robust and regular basis to overcome these.”
See more from MedicalBrief archives:
More allegations of Mediclinic billing irregularities
Mediclinic’s alleged irregular billing sparks forensic probes
Mediclinic claims erodes trust in private healthcare and NHI