A second, former Mediclinic employee, has accused the hospital group of manipulating patient bills, sharing correspondence with News24 that reflects billing changes apparently made by Mediclinic employees to patients’ records.
This comes after another person, also claiming to be a former Mediclinic employee, sent detailed information, in August, to more than 50 principal officers of some of South Africa’s largest medical schemes, alleging widespread manipulation of patients’ clinical coding at six hospitals.
The whistle-blower alleged that, at one hospital, there had been multiple incidents in which the coding on the account of a patient who died in the emergency room had been altered to reflect an ICU death instead.
This is because the fixed fees associated with emergency room deaths are lower than ICU-related fees.
The second whistle-blower claimed to have uncovered evidence of a similar incident, saying after a patient died in the emergency unit at a particular hospital, they found that an ICU file had been opened for the patient. When this was queried, the source was told the emergency unit was a “cost centre”.
The employee also corroborated an allegation that Mediclinic employees manipulated accounts to prevent losses from alternative reimbursement model (ARM) cases. ARM is an agreement between a medical scheme and a hospital to pay a fixed amount for specific medical care or to treat a specific disease.
The alternative would be that the medical scheme must pay for every service rendered. Medical schemes often prefer the ARM option because they believe this may discourage hospitals from providing unnecessary services that schemes have to cover.
But when Mediclinic faces a large loss under an ARM case, the original whistle-blower claims, some employees would manipulate the coding of cases to save the hospital group money.
The second whistle-blower confirmed instances of this, saying a hospital manager who was instrumental in monitoring ARM losses and giving billing instructions now has a senior oversight position at Mediclinic.
One of the examples of billing changes was when intravenous feeding was added to the account of a patient who was in a drug-induced coma, the former employee alleges. The patient did not receive tube feeding – but the case manager was instructed to add it to the bill, they claim.
Tube feeding is not part of ARM and incurs additional costs.
"The patient was never intubated or in a coma, so there was no reason for him to receive TPN,” the source told News24.
When they referred instances of suspect billing changes to a hospital manager, the second whistle-blower was told head office was dealing with the issue and that they should stop pursuing the matter.
But the whistle-blower then referred the issues to another manager and to the Mediclinic ethics hotline, which was managed by KPMG at the time.
No action was taken, said the former employee, who then decided to resign from Mediclinic.
In response to questions about the latest allegations, Mediclinic said ENSafrica was conducting an investigation into the original allegations, and that the allegations should be forwarded to the investigator directly.
Mediclinic appointed Steven Powell, head of law firm ENSafrica's forensics practice, to head the probe.
News24 also asked KPMG why the serious allegations by the former employee were not followed up, but a spokesperson said the company was unable to comment due to client confidentiality, adding that KPMG’s services were terminated in August 2018.
News24 article – Mediclinic storm: More claims that bills were manipulated (Restricted access)
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