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

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