Image By: National Cancer Institute via Unsplash
The original article can be found here.
An independent investigation has cleared Mediclinic of intentionally manipulating billing or coding to save the hospital group money.
Steven Powell, Head of law firm ENSafrica’s Forensics practice, found no evidence of an intentional manipulation. He, however, did find incidents involving mistakes or unintended errors, but they were “random and miniscule” and formed part of the “normal cause of business.” One previous billing problem had led to a disciplinary process for an employee.
Complex investigation
Said Powell: 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 probe began after a whistleblower, who claimed to be a former Mediclinic employee, sent an email to more than 50 principal officers of some of South Africa’s most prominent medical schemes last year. It 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 were analysed.
Alternative reimbursement model allegations
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 whistleblower 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.
Image By: Marcelo Leal via Unsplash
Powell said that the incident referred to by the whistleblower occurred in 2011 when the ARM agreement model was initially implemented. He said that that particular hospital was also a recent addition to the group.
Zero adaptation
Powell said: They didn’t adapt well to the changes, and they 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 are low in comparison to the volume of transactions. The medical funders said to us: ‘Mr Powell, we’d be surprised if you did not find mistakes – mistakes happen from time to time’.”
Mediclinic Southern Africa CEO Greg van Wyk added that they see over 500 000 patients a year. “The industry recognises that errors do take place and ours are within those parameters – and some of those errors can be to our detriment. That is business as usual. With the medical aids, we engage on a robust and regular basis to overcome these errors”.
