• 28 Jun 2016

    SpesNews Volume 132


    Forensic Audits are still being performed in a very generous manner by the various medical schemes and some of the codes being audited are for procedures performed for ultrasound investigations (specifically heart sonar examinations) and modifier applications (like modifier 0013).

    SpesNet offers assistance with the forensic audits where requests are received. Please contact the SpesNet Healthcare Help Line for assistance and to obtain the required documentation. SpesNet would also like to remind practices that similar audits have been performed in the past on the application of the codes used in ICU (1204 / 1205 / etc.) as well as the application of Rule M (electively booked cases) and Rule G (post procedure follow-up consultations performed within the global period).

    Practices utilizing these codes are kindly requested to review their use of these codes and the application of the modifier. Coding queries can be forwarded to SpesNet and the use of the guidelines from societies as well as the Medical Doctor’s Coding Manual is highly encouraged. Coding training is also available via SpesNet for practices who might require a formal course.


    Although forensic audits are at times a real inconvenience to deal with, the reasons behind the implementation of the audits seem to be based on solid facts. The Board of Healthcare Funders’ Forensic Management Unit’s deputy chair, Dr Hleli Nhlapo, purportedly states that between 7 and 15% of medical aid claims are fraudulent ones. To put the figure into perspective, of the estimated R130 billion spent in the private healthcare sector annually, R13 billion could be allocated to fraudulent claims alongside wastage and abuse. It has further come to light that the practitioners operating in these syndicates opted to use low value, high volume claims to commit the fraud. While more difficult to police, this type of behaviour still becomes evident on the various utilisation monitor systems.

    It is generally accepted that most practitioners are ethical, caring professionals. There are unfortunately a few who persist in giving the profession a bad reputation. Bad behaviour from healthcare professionals often leads to medical schemes implementing managed care interventions (like copies or reports or second opinions) that adversely affect the administrative burden of the rest of the ethically operating profession.

    The fraudulent activities clearly identifiable on scheme level include claiming for services:

    • not actually provided
    • provided to someone other than the medical scheme member
    • not covered under the pretence of covered services
    • where the service date is amended to fall within the covered benefit period of patients
    • at a higher level than was originally rendered


    While an estimated 94% of claims that might be fraudulent in nature are discussed at the audit forums, all medical schemes have processes in place to monitor claims and trends on an individual provider level.

    Recently, the SABC (South African Broadcasting Corporation) uncovered fraudulent activities by 150 of its staff members who colluded with healthcare professionals. It stated that it views this type of behaviour in a very serious light and that it is gearing to investigate further where corruption is “probable”. It is also planning to take “stern action” against the perpetrators.

    With more schemes (and now also corporates) opting to clamp down on fraudulent claims, more activity in the forensic sectors are sure to follow.

    SpesNet would like to remind practitioners that fraudulent behaviour transgresses several Acts and could lead to punitive measure instigation. 


    Codes are periodically updated or replaced by new or alternative codes by SAMA and endorsed on society level. These are then communicated to the healthcare professionals. Amidst the excitement around the possibilities the new codes offer, claims containing these codes are often rejected by medical schemes. This naturally leads to obvious frustration and at times exasperation on provider side.

    The unfortunate fact of the matter is that medical schemes are allowed to implement managed care interventions in terms of the Medical Schemes Act. These often include treatment protocols and guidelines pertaining to how the scheme would fund for certain procedures. A medical scheme is consequently under no legal obligation to reimburse for the use of these codes and the responsibility frequently rests on the patient to obtain (from the practitioner) the relevant codes and submit these to the medical scheme prior to any intervention (as part of the pre-authorisation).


    While the off-label use of drugs are common place for some molecules, most medical schemes do not reimburse for these. The Medicines Control Council (MCC) requires the submission of what is commonly referred to as a Section 21 application form where the unregistered use of a drug is contemplated. This form can be downloaded here and it describes the function, process and information required for authorised use of the drug. Naturally, patient (or guardian / legal representative) written consent must always accompany the application.



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