Experiences of physiotherapists audited by South African medical funding schemes

Abstract

Background: Forensic auditing safeguards patients’ funds by investigating billing irregularities of claims submitted to medical schemes. However, billing irregularity audits can be misguided, as indicated in a study conducted in Australia, Canada and the United States. Negative consequences were reported, including attrition, and patients funding their treatments out of pocket. Medical professionals were penalised, without forensic auditors considering alternative explanations for the alleged irregular billing patterns. Small medical practitioners, unable to defend themselves financially, closed their practices, leaving patients without medical care. In South Africa, the experiences of physiotherapists who underwent forensic audits have not been examined.
Objectives: This study explored physiotherapists’ experiences of forensic auditing by medical scheme administrators.
Method: An analytical qualitative study was conducted to interview 14 physiotherapists. Three focus group discussions and 11 individual interviews were conducted. A semi-structured open-ended interview guide was used, analysing the data via open and axial coding.
Results: The first five themes that emerged captured the adverse experiences of physiotherapists. These were (1) ‘unfairly persecuted, judged and penalised’; (2) ‘overpowered and oppressed’; (3) ‘naively entrapped between a rock and a hard place’; (4) ‘distressed with a knife over your head’ and (5) ‘detrimental and hurtful’. In the sixth theme, ‘seeking remedies pre-emptively and preparedly’, the participants made recommendations to prevent similar unwanted experiences.
Conclusion: Physiotherapists experienced significant emotional, financial and professional detriment at the hands of South African medical scheme administrators.
Clinical Implications: The quality of care provided by physiotherapists is adversely affected when forensic audit-related distress occurs.