Business Maverick


Mediclinic says ‘independent’ investigation clears it of dodgy billing allegations

Mediclinic says ‘independent’ investigation clears it of dodgy billing allegations
Vergelegen Mediclinic in Somerset West. (Photo: Gallo Images / Misha Jordaan)

A forensic investigation by ENSafrica has cleared hospital group Mediclinic Southern Africa over anonymous allegations of billing irregularities made last year, not long after the healthcare provider delisted.

In a statement issued on Wednesday, Mediclinic said it was encouraged by the forensic investigation’s conclusions that “there is no intentional practice of manipulating billing or coding at a hospital or group level, and that there has been no evidence reflecting a culture of victimisation”.

Mediclinic appointed ENSafrica to conduct a comprehensive and independent forensic investigation after allegations made anonymously on 22 August last year.

The hospital group says the investigators had “unfettered access” to investigate and determine whether there was any substance to the allegations made against six Mediclinic hospitals in Gauteng and the Western Cape – Mediclinic Kloof, Mediclinic Morningside, Wits Donald Gordon Medical Centre, Mediclinic Cape Gate, Mediclinic Vergelegen and Mediclinic Panorama.

The ENSafrica investigation, led by white-collar crime prosecutor and forensics lawyer Steven Powell, also randomly selected a further six hospitals to test for billing irregularities.

After failing to bring the matter to management’s attention, the whistle-blower sent an email in August last year to various media, the chief executive officer at Mediclinic and about 50 medical schemes (there are around 74 medical schemes in total), detailing explosive allegations that certain hospitals within the Mediclinic Group had been manipulating patient bills to save money.

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 was employed at these 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 investigation included interviews with Mediclinic staff and a review of more than 120,000 emails and documents.

ENSafrica’s investigation confirmed:

  • Mediclinic is an ethical organisation with sound controls and governance in the billing environment;
  • There is no evidence of an intentional practice of manipulating billing or coding;
  • There are neither incentives nor direct financial benefits which could encourage Mediclinic and its staff to undertake account manipulation.

“ENSafrica was very satisfied with the level of access Mediclinic provided to allow us to conduct a thorough investigation into the anonymous allegations.

“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,” Powell said, adding that this was supported by the existence of multiple checks and balances on billing practices.

While the ENSafrica investigation seems to have cleared Mediclinic’s conscience, the concurrent investigations by various medical schemes are still to be publicly aired.

At least three of the country’s largest medical scheme administrators told Daily Maverick last year that they would conduct their own independent investigations and review all their billing from Mediclinic with a fine-tooth comb. DM


Comments - Please in order to comment.

  • Jayce Moodley says:

    It will always be a concern when an accused Party runs a premature parallel investigation and announces an outcome that is favourable prior to the completion of the process by the aggrieved party. These outcomes will always remain questionable.

  • Sliver Fox says:

    I suspected as much, Mediclinic has always come across as a company that actually lives its core values, unlike many other companies who’s values exist only on paper, in stark contrast to their reality. This was also evident from their submissions during the Health Market Inquiry years ago.

  • Geoff Coles says:

    Mind you, from personal experience, there are cosy agreements between Administrators and Mediclinic regarding total costs I queried iro a knee replacement. Neither would disclose detail which seemed excessive.

Please peer review 3 community comments before your comment can be posted


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