A University of Pretoria study has revealed a troubling reality in South Africa’s healthcare system. Medical aid audits meant to curb fraud are instead leaving physiotherapists fearful, financially strained and professionally scarred.
Physiotherapist and academic Lesley Meyer led the research, which found that medical scheme forensic audits often result in punitive action and not corrective oversight. Instead of fairly identifying billing errors, practitioners reported that they are being treated as guilty from the outset, with little transparency or opportunity to defend themselves.
‘Many felt they were subjected to a witch hunt’
“Participants reported feeling unfairly targeted and singled out, describing the audit process as unfairly conducted. Many felt they were subjected to a witch hunt,” Meyer said.
Forensic audits are intended to detect billing irregularities and protect medical scheme funds. However, the study, published in the South African Journal of Physiotherapy, found that some schemes extend audits beyond their legal scope and illegally retain recovered funds.
“In practice, however, these audits often extend beyond their legal scope and adversely affect the profession, while pocketing patients’ savings instead of returning these funds to the patients in accordance with the Medical Schemes Act.”
Schemes often reclassify potential fraud as administrative errors
Under Section 59(3) of the Medical Schemes Act, cases involving suspected fraud exceeding R100,000 must be referred to authorities such as the Health Professions Council of South Africa or the SAPS.
The study found that schemes often investigate internally without external oversight.
“However, the study found that schemes mistrust these authorities, so they bypass that requirement by reclassifying potential fraud as administrative billing errors.”
‘Misuse, coercive practices and a lack of accountability’
This, Meyer said, creates a loophole that opens the door to “misuse, coercive practices and a lack of accountability”.
The research further found that practitioners were sometimes accused of overbilling or coding errors without being given access to the evidence used against them, and were pressured into signing Admissions of Debt (AOD) to avoid escalation.
These repayments ranged from R54,000 in solo practices to as much as R4.5-million for group practices.
“For those who sign the AOD it means they’re admitting that they’re guilty … But participants felt like they didn’t have a choice, because they weren’t getting any money from the schemes,” Meyer said.
Outdated billing codes
The study also highlighted how South Africa’s outdated billing system is compounding the problem. Tariff codes, last updated in 2006, have not kept pace with modern treatment methods, forcing practitioners to use outdated classifications or leave certain treatments unbilled altogether.
Participants described severe emotional distress, with some comparing the experience to trauma. One said: “Seven months of watching my father die was easier than this experience.”
Lack of effective oversight
The research further found a lack of effective oversight, with complaints to the Council for Medical Schemes often going unanswered, leaving practitioners without a clear avenue for appeal.
Meyer has called for reforms including independent oversight, standardised audit procedures and greater transparency.
“The release of this report is an important step toward institutional accountability and reform … However, the full implementation of its recommendations remains critical to ensure fair audit practices and to restore trust among healthcare providers.”
