---
title: "Council for Medical Schemes ‘deeply disturbed’ by Mediclinic fraud allegations"
description: "A whistle-blower came forward last week with explosive allegations that six Mediclinic hospitals in Gauteng and the Western Cape have been manipulating patients’ bills to save the hospital group money."
type: "NewsArticle"
publisher: "Daily Maverick"
site: "https://www.dailymaverick.co.za"
section: "CALL FOR PROBE"
author: "Neesa Moodley"
author_url: "https://www.dailymaverick.co.za/author/neesa-moodley/"
canonical_url: "https://www.dailymaverick.co.za/article/2023-08-27-council-for-medical-schemes-deeply-disturbed-by-mediclinic-fraud-allegations/"
published: "2023-08-27T21:51:12"
updated: "2023-08-28T12:07:10"
lang: "en-ZA"
word_count: 452
---

# Council for Medical Schemes ‘deeply disturbed’ by Mediclinic fraud allegations

> A whistle-blower came forward last week with explosive allegations that six Mediclinic hospitals in Gauteng and the Western Cape have been manipulating patients’ bills to save the hospital group money.

By Neesa Moodley · Published 27 August 2023, 23:51 SAST · Updated 28 August 2023, 14:07 SAST

## Key points
- The Council for Medical Schemes is calling for an investigation into the alleged fraudulent activities of Mediclinic, which could have caused medical scheme members to suffer unnecessary out-of-pocket expenses, and is encouraging members to report any suspicious activity.
- Council for Medical Schemes expresses concern over allegations of fraudulent activity by Mediclinic.
- Whistle-blower claims six hospitals manipulated patient bills to save money.
- Council calls for comprehensive investigation into possible fraudulent activity.
- Members of medical schemes encouraged to report suspicious activity.

## Content

The Council for Medical Schemes has sounded the alarm that as the medical schemes regulator, it is “deeply concerned and disturbed by the allegations of billing and other fraudulent activities levelled against hospital group Mediclinic”.

Although the council has not yet received a formal complaint, the allegations in recent media reports are viewed in a serious light. As per various media, including[*News24*](https://www.news24.com/fin24/companies/fraud-claims-mediclinic-names-independent-investigator-20230824)*,*[*eNCA*](https://www.enca.com/top-stories/mediclinic-probes-suspected-fraudulent-billing) and [Radio 702](https://www.702.co.za/articles/482529/alleged-mediclinic-fraud-would-take-huge-collusion-and-corruption), a whistle-blower came forward last week with explosive allegations that six Mediclinic hospitals in Gauteng and the Western Cape have been manipulating patients’ bills to save the hospital group money. The whistle-blower forwarded the claims to Mediclinic management, *News24* and several medical schemes.

**Codes changed for more lucrative billing**

When hospitals submit medical bills to medical schemes for payment, they have to submit an ICD-10 code, which varies depending on the procedures carried out or the medication administered.

The whistle-blower, apparently a former manager who worked at at least one of the six hospitals, told *News24* that, for example, “When a patient died in a hospital emergency room, sometimes Mediclinic case managers were expected to change their accounts to reflect an ICU death instead. This is because of the fixed fees associated with emergency room deaths, which are lower than ICU-related fees.”

The Council for Medical Schemes registrar, Dr Sipho Kabane, says his concern stems from the real possibility that medical scheme member funds may have been acquired by Mediclinic hospitals through fraudulent means.

“The consequences of these fraudulent transactions would have led to scheme members suffering premature exhaustion of their funds, leading to unnecessary out-of-pocket and catastrophic health expenditures,” he said. According to the latest annual council report, medical scheme members paid more than R32-billion in out-of-pocket payments last year.

**Reimbursement called; for pending investigation**

Kabane adds, “We \[the council\] are interested in the extent and depth of these possible fraudulent acts by hospitals. We are calling for a comprehensive, unhindered and speedy investigation of these allegations by an objective and trusted authority.”

[Mediclinic,](https://www.dailymaverick.co.za/article/2023-07-02-mediclinic-discharges-its-final-set-of-results-after-37-years-on-the-jse/) which is no longer listed on the JSE following[a buyout by a Remgro/MSC consortium](https://www.dailymaverick.co.za/article/2022-08-04-mediclinic-accepts-remgro-consortiums-3-7bn-offer/), has appointed Steven Powell, head of law firm ENSafrica’s forensics practice, to head an independent audit following the claims.

Kabane says the investigation should not just aim to apprehend the responsible parties, but should also ensure that the funds involved are quantified and returned to their rightful owners — the medical scheme members.

Members of medical schemes are encouraged to telephonically report any suspicious activity or lodge a complaint at (086) 673-2466 or to email [complaints@medicalschemes.co.za](mailto:complaints@medicalschemes.co.za). If you have had experience of incorrect billing - with Mediclinic or another hospital group, share your story with us - email neesa@dailymaverick.co.za **DM**