- University of Pretoria study finds physiotherapists experience medical aid forensic audits as punitive and traumatising.
- Practitioners report pressure to sign admission of debt agreements without seeing evidence against them.
- Research calls for oversight, fair procedures, and reform of forensic audit practices.
A University of Pretoria study has found that medical aid forensic audits, intended to detect billing irregularities, are leaving physiotherapists fearful, stigmatised, and traumatised even when no wrongdoing is proven.
The research, led by physiotherapist and extraordinary lecturer Lesley Meyer from the university’s Department of Physiotherapy, examined the experiences of practitioners who have undergone forensic audits by medical schemes and found that processes intended to protect medical scheme funds are often experienced as punitive rather than corrective.
Participants described being treated as suspects rather than healthcare professionals and reported severe distress caused by investigations that offered little transparency or recourse.
“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.
Legal loopholes and coercive practices
The study, published in the South African Journal of Physiotherapy, also highlights systemic problems in the way medical aid forensic audits are conducted under the Medical Schemes Act 131 of 1998.
Section 59(3) of the Act allows medical schemes to investigate inconsistencies in claims. However, where suspected fraud, waste or abuse exceeds R100 000, the matter should be referred to the Health Professions Council of South Africa or the South African Police Service.
According to the research, some schemes bypass this requirement by reclassifying potential fraud as administrative billing errors. This allows them to conduct internal investigations without external oversight, creating what Meyer describes as a loophole that opens the door to misuse and coercive practices.
Practitioners reported being accused of coding errors or overbilling without being given access to the evidence used against them. Some said they were pressured to sign admissions of debt to prevent escalation of the investigation.
The study recorded repayment demands ranging from R54 000 for a solo practice to R4.5 million for a group practice. “For those who sign the Admission of Debt, it means they’re admitting that they’re guilty, which is against the Health Professions Act, because if you are guilty, it means you’ve committed fraud, and you can lose your licence,” Meyer explained.
“But participants felt like they didn’t have a choice, because they weren’t getting any money from the schemes.”
Outdated billing codes triggering disputes
The research also points to South Africa’s outdated physiotherapy billing system as a factor contributing to forensic audits.
Tariff codes used by medical schemes were last updated by the Competition Commission of South Africa in 2006 and have remained unchanged since then. Because schemes do not recognise new or unlisted codes, practitioners must rely on outdated tariffs to describe modern treatment methods.
This mismatch between current clinical practice and old billing codes can create irregular claim patterns that trigger investigations, even where treatments are evidence based. Some physiotherapists told researchers they sometimes avoid billing for certain treatments entirely because no suitable tariff code exists.
Trauma and professional impact
Participants described the emotional impact of medical aid forensic audits as severe and lasting. Meyer said the distress reported by practitioners often resembled trauma responses similar to post-traumatic stress disorder.
Some reported physical reactions, such as sweating or anxiety, when encountering reminders of the medical scheme involved in the investigation. Others described reputational harm after being blacklisted by schemes.
One participant told researchers that the experience was more distressing than watching a loved one die. “Seven months of watching my father die was easier than this experience,” the participant said.
The study also found that practitioners whose payments were blocked during investigations sometimes converted their practices into cash-only services in order to survive financially. In some cases, those practices were later blacklisted because scheme administrators could not apply offset controls to claims.
Calls for oversight and reform
A key concern identified in the research is the absence of effective oversight over medical aid forensic audits. While practitioner conduct is regulated by the Health Professions Council of South Africa, medical schemes themselves are overseen by the Council for Medical Schemes.
According to the study, some practitioners who complained to the regulator received no response, leaving them without an appeal mechanism when they believed they had been treated unfairly.
Meyer argues that the current system leaves practitioners vulnerable to arbitrary decisions and procedures that undermine basic principles of fairness.
“These hostile auditing processes contradict the principle of procedural fairness,” Meyer said, adding that fair procedures require transparency, impartiality and an opportunity for the accused party to be heard.
Training and future reforms
The study recommends strengthening forensic literacy among physiotherapists so that practitioners understand the risks and processes involved in medical aid forensic audits.
In response, Meyer has introduced five lectures based on her findings into the fourth year physiotherapy curriculum at the University of Pretoria to help prepare students for the realities of private practice.
The research also proposes broader reforms, including establishing an independent oversight body, standardising investigative procedures and ensuring that practitioners have access to evidence, the right to respond to allegations and the ability to appeal decisions.
Since the study was completed, an independent legal panel reviewing how Section 59(3) of the Medical Schemes Act is applied in forensic audits has released its final report. Meyer says the findings confirm many of the concerns raised in her research, including retrospective audits, limited transparency and potential misuse of investigative powers.
“The release of this report is an important step toward institutional accountability and reform,” Meyer said. “However, the full implementation of its recommendations remains critical to ensure fair audit practices and to restore trust among healthcare providers.”
She added that most practitioners interviewed were not trying to avoid accountability but were asking for a fair process. “The people I interviewed were not trying to avoid accountability. They wanted fairness. They wanted to be heard. If we don’t address the lack of oversight, we risk losing good practitioners and damaging trust in the healthcare system itself.”
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