Physiotherapists' irregular billing NOT all fraud
Physiotherapists' irregular billing not all fraud
The article, Medical schemes lose R28bn to fraud every year only considers the funder’s view. It was reported that 3% to 10% of healthcare fraud was attributed to fraud, waste and abuse (FWA), while R500m was recovered from healthcare costs through audits conducted on medical professionals. Although there are clear cases of fraud, such as false claims for services never delivered, the article also covers outliers using certain codes more than their peers.This “suspicious behaviour”, therefore, flags the practitioners, which results in an audit. Meyer, Mostert, and van Staden (2024) conducted a study on physiotherapists in South Africa who had undergone forensic audits by medical funding schemes to explore and describe their experiences.All audited physiotherapists interviewed in this study had been accused of being outliers without the medical schemes considering that they had valid reasons for irregular billing patterns, such as special interest practices.These practices treated specific and limited conditions, resulting in the physiotherapists only using certain billing codes compared to their peers. The medical scheme investigators contacted these physiotherapists but disregarded all evidence of innocence, including actuarial reports, and advocate or legal representation.Additionally, patients’ claims sent through for payment to the medical schemes were not paid to the physiotherapists. Instead, payment was deducted from the “alleged” debt owed to the scheme, described as offset. However, patients were informed that their claims had been paid when no money had been paid to the physiotherapists.If the physiotherapist was or became a cash practice, the practitioner was blacklisted, and defamatory letters were sent to the patients informing them they would not be reimbursed if they continued to see that physiotherapist.Throughout the audit process, the physiotherapists were repeatedly told that they had NOT committed FWA, only billing irregularities, therefore, the Health Professions Council of South Africa (HPCSA) was not involved.The scheme has carte blanche to conduct the audits without contestation due to them using Section 59.3 of the Medical Scheme Act to do so. The medical schemes were not transparent in the audit process, extending the audit by requesting more information, including patient notes that were scrutinised for any discrepancy in which to entrap the physiotherapists further. Physiotherapists were threatened with larger debt amounts, forcing them through fear, to sign an admission of debt (AOD) for the original audited amount.Physiotherapists were accused of poor note-keeping for not writing the duration of the treatment in the notes when the time was both in the description of the code and the physiotherapists’ diary.Additionally, there was a clear discrepancy in understanding the code descriptions created by the South African Society of Physiotherapy (SASP), which has custodianship of the codes given to them by the Competition Commission. The descriptions and usage of these codes have not changed since 2006 when the Competition Commission last gazetted them.Therefore, physiotherapists are being exposed to unfair audits as new codes to describe new treatment techniques are disregarded by the medical schemes. Schemes further overpower physiotherapists by stating physiotherapists’ understanding of the codes is incorrect. However, these codes have specific rules and regulations according to the National Health Price Reference List (NHPRL) that have been encoded into the electronic data interchange systems (EDI) preventing codes from being used incorrectly.Additionally, this EDI system flags codes on both the physiotherapists and the schemes’ sides in real time, preventing billing irregularities.According to the contractual prescription period of Regulation 6 of the Medical Schemes Act, no claim will be considered for payment by the medical schemes if it has not been submitted within 120 days. Since irregularities are flagged by artificial intelligence in real-time, most claims are submitted without any issues, according to the NHPRL, and paid in full within 30 days. However, the schemes are backdating audits up to three years, which is well past the contractual prescription period.The Solutionist Thinkers requested that Section 59.3 be investigated in terms of racial discrimination in 2021 (“Medical schemes deny ‘racist’ algorithm claim”). However, the investigation has still not been completed and has once again been extended.Additionally, claims that are paid to physiotherapists are paid from the patients’ savings. According to the Medical Schemes Act, all savings must be treated as trust fund money by the schemes and returned to the patient when they leave the scheme, or to their next of kin if they die.However, money clawed back from the physiotherapists was not being returned to the patients’ savings, instead, it was returned to the funder pool “to benefit all members”. Additionally, the scheme investigators were seen as being biased, as they were incentivised to reach certain monetary targets and when these were reached, their entire family went to the Maldives.Physiotherapists experienced much hurt and detriment to both their personal and professional lives: physiotherapists reported that one died, one had a stroke, and one had a miscarriage. One emigrated, one gave her practice to her locums, and one could not touch a patient for two years for fear of billing, even though she was the breadwinner. Physiotherapists experienced increased distress due to a lack of organisational support from organisations tasked with protecting the profession.Six themes emerged from the findings in the study, “Unfairly persecuted, judged, and penalised”, “Overpowered and oppressed”, “Naively entrapped between a rock and a hard place”, “Distressed with a knife over your head”, “Hurtful and detrimental”, and last, “Seeking remedies pre-emptively and preparedly.”The full article, “Physiotherapists’ experiences of forensic auditing by medical schemes of South Africa”, is soon to be released in a research journal.Further supporting Information:
“Audit of Agony: Artistic depiction of Physiotherapists’ Perceived Persecution.”
Please open it and navigate to “7 Day 2 Hall 2” to view the relevant portion from 21:17 to 58:04.
Letter by Lesley Meyer (Physiotherapy Private Practice Owner, MPhysT)
cope.saphysio@gmail.com
