The medical schemes regulator has called for a swift, thorough investigation of allegations of billing fraud an anonymous whistle-blower made against private hospital group Mediclinic.
A person identifying as a former Mediclinic employee emailed medical schemes and journalists last week, alleging billing codes were manipulated to inflate claims submitted to medical schemes.
The email, which has been seen by Business Day, describes alleged billing manipulation at six Mediclinic hospitals at which the whistle-blower claims to have worked.
The Council for Medical Schemes (CMS) said it is concerned about the allegations.
“We are calling for a comprehensive, unhindered and speedy investigation of these allegations by an objective and trusted authority,” it said in a statement on Friday.
“The investigation should not just aim to get the names of the responsible parties apprehended but should also ensure that the funds involved are quantified and returned to their rightful owners — the medical scheme members,” it said.
The CMS said inflated hospital claims could lead to members running out of funds prematurely and facing “unnecessary out of pocket and catastrophic health expenditures”.
SA’s biggest medical scheme administrator Discovery Health said it initiated its own investigation. “We’re in touch with top leadership at Mediclinic and assured of their efforts to establish the truth. There is good faith in the 30-year contractual relationship and we will do all (that is) needed to guarantee schemes and members of the fidelity of their funds and claims,” said Discovery Health CEO Ryan Noach.
He said the CMS’s statement about members being at risk of running out of funds is incorrect with regard to members of Discovery Health Medical Scheme (DHMS), as it did not impose limits on claims for hospital admissions. DHMS is SA’s biggest open medical scheme and Discovery Health’s biggest client.
Mediclinic said it appointed independent forensic expert Steven Powell of law firm ENSafrica to review the accusations and implicated hospitals.
Mediclinic said it views the accusations in a serious light but is confident Powell’s investigation will confirm its billing processes are accurate and ethical.
Profmed principal officer Craig Comrie said the scheme is still gauging the potential effect of the alleged billing fraud. “Regardless of the scale of the allegations ... we are concerned about the culture of upcoding fees and abuse in billing behaviours which need to be addressed,” he said.
Momentum executive head of marketing Damian McHugh said the scale of the alleged fraud is unclear at this stage, but Momentum sees the claims in a “very serious” light and is investigating.
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