The National Department of Health said it noted with concern allegations of patient bill manipulation at private hospital group Mediclinic, but said it was not in a position to investigate private hospitals as they remained relatively unregulated.
This while it engaged with the Council for Medical Schemes to direct regulated medical schemes to investigate.
In an email from an anonymous source, the person identifying themselves as a whistleblower said they worked as a clinical case manager and coder, and alleged that at the hospitals, patients’ conditions were manipulated to either bill at an ARM (alternative reimbursement model), or coding was used to “carve an account out” to bill for services where the loss would be too significant for the hospital.
“Case managers are also expected to ‘open’ in-hospital accounts for patients who died in the emergency room, and these accounts are mostly ICU accounts because of the high cost of resuscitation medication, and were moved from the emergency room account to the ‘hospital ICU account’ because the fixed fee for these high cost incidents again resulted in higher losses for the hospital,” the source said.
They detailed incidents at six hospitals in the Western Cape and Gauteng.
At Mediclinic Cape Gate, they alleged high-cost emergency unit medication was transferred to the in-hospital account for admitted patients to prevent the emergency unit from being “a cost centre”.
At Mediclinic Vergelegen, its alleged that an in-hospital ICU claim was opened for patients who died in the emergency unit.
The whistle-blower said they resigned because they felt the company was not living up to its ethics, and were afraid that if this was raised, they would be victimised.
Mediclinic said it had commissioned an independent audit by an external expert to review the accusations.
“Mediclinic views these accusations in a severe light as they affect vital relationships with health-care funders and patients. Mediclinic prides itself on applying uncompromised ethical practices throughout every aspect of its entire business and is proud of its reputation as a values-driven hospital group providing care that one can trust.
“Mediclinic is confident that the audit will confirm that its billing processes are accurate and ethical. However, should the external experts find any accusations to be true, Mediclinic will not hesitate to act decisively and appropriately on the findings,” the hospital group said.
National Department of Health spokesperson Foster Mohale said: “While this is clearly of concern in that reimbursements were potentially manipulated to achieve a particular objective, the department is not in a position to undertake any form of investigation regarding the said allegations.
“The reason for this is that private hospitals remain relatively unregulated, except with regards to the licensing processes that are the purview of the provincial departments of health.
“The Department of Health is finalising the regulations operationalising Section 36 to Section 40 of the National Health Act, in relation to Certificate of Need. As per the recommendation of the Health Market Inquiry, these regulations will empower the minister of health to regulate health establishments and health-care providers and their conduct.
“Unfortunately, health-care providers have challenged the promulgation of the Certificate of Need and the matter is still in the courts. Medical schemes, regulated by the Council for Medical Schemes, generally have forensic investigation units that focus on looking into such matters.The department is engaging with the council to direct the regulated medical schemes to investigate the allegations. The department recommends that the matter be reported for investigation by the relevant authorities.”
Cape Times