Uncovering the truth: how forensic audits affect physiotherapy practices
Research conducted by Lesley Meyer, an extra-ordinary lecturer at UP’s Department of Physiotherapy, explored the lived experiences of physiotherapists who have undergone such audits.
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South Africa's healthcare landscape is facing growing scrutiny as a groundbreaking study from the University of Pretoria highlights serious ethical and procedural failings in how medical schemes conduct forensic audits of physiotherapists. These audits, designed to identify billing irregularities, instead leave practitioners feeling fearful, stigmatised, and psychologically harmed, raising urgent questions about accountability and justice in healthcare.
Conducted by Lesley Meyer, an extraordinary lecturer at the University of Pretoria's Department of Physiotherapy, the study delves into the lived experiences of physiotherapists subjected to forensic audits. What Meyer discovered was alarming: audit practices often resemble punitive measures instead of serving as corrective actions, causing distress without substantiating claims of wrongdoing.
While forensic audits are ostensibly created to safeguard medical scheme funds and protect patients' contributions, Meyer's findings, published in the latest edition of The South African Journal of Physiotherapy, reveal a disturbing trend of overreach by these schemes. Many audits extend beyond their legal remit, effectively stripping away important patient savings instead of returning them per the Medical Schemes Act.
Under Section 59(3) of the Medical Schemes Act of 1998, schemes are permitted to investigate claims inconsistencies, demanding external oversight when alleged fraud, waste, or abuse exceeds R100,000. However, Meyer’s research illuminated a troubling bypass of these essential checks. Distrustful of the Health Professions Council of South Africa (HPCSA) and the South African Police Service, schemes frequently recategorise possible fraud as administrative billing errors to pursue internal investigations without the necessary external scrutiny.
“Participants reported feeling unfairly targeted and singled out, describing the audit process as a witch hunt,” reported Meyer, who also practices as a physiotherapist. Many practitioners spoke of being treated as suspects, suffering from significant emotional trauma inflicted by a process lacking transparency and recourse.
The situation is further complicated by South Africa's outdated billing system. The competition commission last updated tariff codes in 2006, forcing physiotherapists to utilise antiquated codes for modern treatments. Consequently, some therapies are left unbilled, subjecting practitioners to accusations of overbilling or coding errors, often without access to evidence against them.
Some physiotherapists have felt pressure to sign an Admission of Debt (AOD), an admission of guilt used to avoid further escalation of their cases. Reports revealed financial implications varying greatly, with one individual practice facing claims as high as R54,000 and a group practice confronting R4.5 million.
Moreover, those who signed AODs risked breaking the Health Professions Act, which could lead to severe consequences, including the loss of their professional license. Yet, many felt they had no alternative due to protracted payment blockages from medical schemes.
One therapist described the emotional toll succinctly: “Seven months of watching my father die was easier than this experience,” illustrating the gravity of the trauma linked to such audits.
Adding to the complexity, the study found that the auditing procedures lacked external oversight. While the Health Professions Council regulates practitioner conduct, the Council for Medical Schemes oversees the schemes. Many participants felt ignored when they sought recourse from this council. This regulatory gap leaves physiotherapists vulnerable to arbitrary decisions, devoid of an appeal mechanism when facing perceived injustices.
Meyer’s findings suggest that the distress resulting from these audits mirrors post-traumatic stress disorder. Practitioners disclosed physical reactions to reminders of audits, evidencing the long-term psychological impact of these audits on their well-being.
To address these issues, the study recommends the introduction of forensic literacy to the curriculum of physiotherapy training. Meyer has already begun implementing lectures based on her findings for fourth-year physiotherapy students, aiming to fortify them against potential audit challenges in their careers.
Furthermore, Meyer advocates for a comprehensive framework facilitating safety and voice for practitioners, including the establishment of an independent oversight body, standardisation of investigative procedures, and ensuring audited practitioners can access necessary evidence to respond to allegations.
The culmination of Meyer’s research has coincided with the release of a report by an independent legal panel reviewing the application of Section 59(3) of the Medical Schemes Act. This report corroborates several issues raised in her study, such as retrospective audits and a lack of transparency, thus affirming a pressing need for institutional reform.
“The findings validate our concerns,” said Meyer. “Yet, ensuring the full implementation of the report’s recommendations is crucial to restore trust and fairness in audit practices among healthcare providers.”
As South Africa grapples with these systemic issues, the imperative remains clear: to foster an environment where medical professionals can operate without fear, ensuring patient care and integrity within the healthcare system are not compromised.