Fourteen private-practice physiotherapists, registered with the HPCSA and audited by medical schemes, were purposively recruited through purposive and snowball sampling. All audited physiotherapists accepted and gave written informed consent (Meyer et al. 2024).

Fourteen interviews were conducted: eleven personal interviews and FGDs comprising the group sizes of five, six and two participants, during three sessions (Meyer et al. 2024). The FGDs were used to expand on data gathered during individual interviews to elicit shared experiences that may not have emerged in the separate settings (Nyumba et al. 2018). Data were collected via Cisco Webex (https://signup.webex.com/sign-up), which recorded and automatically transcribed the interviews. Four trained interviewers conducted the sessions, three conducted three interviews each and one conducted four, with the lead author facilitating one FGD (Kallio et al. 2016; Meyer et al. 2024).

To thematically analyse the data, open coding was initially used, followed by axial coding, which identified the themes and subthemes (Medelyan 2019; Meyer et al. 2024). The main author conducted 11 rounds of data analysis, and the other authors corroborated the findings during ongoing conjoint meetings. Interviews were conducted as participants became available and in group discussions intermittently after every few individual interviews. Analysis of the first FGD resulted in saturation and was confirmed through recurring themes in subsequent interviews and FGDs. Bracketing was applied to minimise the bias and enhance the interpretive validity (Dörfler & Stierand 2021; Meyer et al. 2024). Reflection notes were made throughout using memoing and field notes and member checking further ensured data trustworthiness (Meyer et al. 2024; Nowell et al. 2017).

Ethical clearance to conduct this study was obtained from the Faculty of Health Science Research Ethics Committee at the University of Pretoria (Reference no: 135/2022). All 14 physiotherapists who participated in this study gave written informed consent to participate in this study and for their data to be used in articles.

Participants reported feeling unfairly targeted and singled out, describing the audit process as ‘unfairly conducted’. Many felt they were subjected to ‘a witch hunt’, with one participant noting that their practice, which consisted of ‘15 physios’, with a ‘specific orthopaedic range’, was unfairly scrutinised. Others, like those in a ‘paediatrics’ and a ‘neuro rehab practice’, felt they were judged for being outliers. Others were audited for factors such as seeing high volumes of patients, whether in group practices or as sole practitioners who occasionally used locums for ad hoc support. A sole practitioner explained that they were accused of ‘seeing too many patients as a sole practitioner, using locums’. These experiences left participants feeling persecuted and misunderstood.

Participants felt that the investigators lacked the necessary clinical knowledge to accurately assess their practices, with one noting that the team consisted of ‘actuarial scientists, accountants, attorneys, and maybe a forensic auditor’. This perceived mismatch in expertise led to frustration, as physiotherapists believed the investigators failed to grasp the nuances of physiotherapy coding. As one participant pointed out, ‘I have a fairly good working knowledge of physiotherapy coding’, highlighting the gap in understanding between physiotherapists and investigators. Moreover, participants emphasised that they had ‘used these codes forever’, referring to gazetted tariff codes such as after hours, myofascial release, rehabilitation and complex evaluation, which have been unchanged since 2006. Physiotherapists were unaware that the scheme administrators scrutinised their application, which further exacerbated the sense of unfair judgement.

Participants felt that the investigators were driven by incentives that compromised their objectivity, with one physiotherapist, who had treated one of the investigators, reporting that the investigator told her she had ‘won the incentive’ for reaching the target and that ‘their entire family went to the Maldives’. This perceived conflict of interest contributed to a sense of mistrust, as participants believed that investigators would default to accusatory and derogatory positions, even in the face of doubt. Despite these concerns, participants were united in their stance, ‘there is fraud, and the fraudsters need to be stopped’, emphasising that any allegations ‘need to be proven’ through a fair and rigorous process.

Physiotherapists expressed that the processes were ‘unfairly conducted and one-sided’ as the scheme investigators repeatedly ‘shifted the goalposts’. These speak of misalignment between the penalty and the offence. When the understanding of codes was divergent, participants experienced being ‘hauled over the coals’. This came unexpectedly and made them feel that they are destined to ‘burn in hell for the rest of your life’, despite empathetic physiotherapists undercharging their patients: ‘Most of the physios doing a good job, actually undercharge their patients’.

Participants felt that penalties imposed were unjust, with one stating that ‘the punishment given was completely out of proportion to the [alleged] “crime” committed’. Specifically, physiotherapists were fined varying amounts, including ‘ZAR1.2 million and ZAR4.5 million’ for ‘poor note taking’, such as not recording the duration of each treatment session. Participants felt these charges were unwarranted, noting ‘we’ve got the diary to prove it [length of treatment]’. The code descriptions were also gazetted in the National Health Price Reference list (NHPRL), which specifies the required length of treatment time when charging rehabilitation. Additionally, the code descriptions were gazetted in the NHPRL. Despite this evidence, auditors rejected it, leaving physiotherapists feeling that the experience was ‘quite upsetting’. Furthermore, participants argued that the medical schemes’ decision to retain member savings, rather than refunding them, was unjust, ‘because then they are actually making more money off their clients, which is fraudulent’.

Physiotherapists felt that the forensic investigators overpowered them by their control over the payment process, describing experiences of being ‘locked up in rooms, shouted at, forced to say that they were guilty’. The forensic investigators were perceived as biased, with one participant stating she felt the investigators ‘have a genuine hatred for physios’, recalling a scheme investigator saying, ‘You physio[therapist]s are all the same. You’re filthy, money-hungry, greedy people, and you all try and make as much money as you can; it’s disgusting’.

This perceived animosity had a profound impact on participants, contributing to feelings of depression when their evidence was dismissed. Despite a comprehensive ‘65-page forensic report’ prepared by a forensic actuary in consultation with a physiotherapist, the investigators ‘would not even look at it’. Instead, participants were threatened with severe consequences, with the investigators stating that ‘They will audit every single person on the list’, and they ‘will take back that money’.

Physiotherapists felt overpowered by the scheme investigators’ control over payment processes. As one participant noted, ‘I never received a cent from them’, highlighting the investigators’ ability to withhold payments and use this as leverage to force participants to comply. This power imbalance was further exacerbated by the prolonged audit process, which was extended, ‘five months’ or longer, causing significant distress and limiting participants’ ability to operate their practices.

The investigators’ tactics were perceived as coercive, with participants being forced to either sign an AOD or face continued blockages on payments, effectively turning them into cash practices. Physiotherapists operating as cash-based practices were ‘blacklisted’ because scheme administrators could not use offset controls to manage claims. Despite contacting the SASP and seeking legal counsel, attempts to resolve the issue were ignored, and schemes compounded the situation by informing patients that ‘they would no longer be reimbursing services’. The physiotherapist was left with few options. One participant captured the sense of injustice, stating, ‘They blacklisted me’.

Furthermore, some participants were re-audited for the ‘same codes’, with one noting, ‘You’re re-auditing me on the same codes that I’m not doing’, demanding reversal of another 3 years of claim payments. One such physiotherapist protected his practice by making a deal. ‘How about I pay you a certain amount of money a month, every month, until the SASP codes change’.

Participants felt trapped in a state of uncertainty, with one noting, ‘you don’t know what you’re in for’. The financial burden of legal fees added to their stress, as ‘everything that your lawyers finally sign[s] off … you pay for’. This created a sense of constant apprehension, with participants feeling like ‘you’ve always got this knife [over your head]’ because of the perceived unfairness of the process. As one participant put it, ‘It’s shocking, it’s unfair’. The concentration of power in the hands of the investigators was particularly galling, with participants arguing that ‘they cannot be judge, jury, and executioner’.

The sense of entrapment was further exacerbated by the participants’ feeling that they were being set up, with the investigators ‘set[ting] a trap’ through divergent rules and contradictory behaviour. Participants felt powerless to defend themselves, describing the experience as facing ‘this big bully’ when ‘you’re too small to fight’. The schemes seemed to operate with impunity, like ‘a law unto themselves’, making it difficult for participants to understand their motivations, other than a perceived focus on extracting money. As one participant summed it up, ‘we don’t really know what they’re after, except for money’.

Participants felt deeply affected by what they perceived as false accusations from the medical scheme, leading to uncertainty about coding and billing practices, with one participant admitting, ‘I just don’t bill for it’ [A second condition]. This uncertainty stemmed from a conflict between their duty to prioritise patient care, as encapsulated in the phrase ‘our patients come first’, and the audit process invalidated their commitment to putting patients first.

The distress participants experienced encroached on all aspects of their lives, ‘it was consuming my everything’. Their lives were evasively affected, including how they treated their patients, shopping and interactions with friends and family, draining them physically. ‘My wife said … “You’ve got to start sleeping [and] eating because you’re just wasting away”’. This was also expressed as ‘I was in tears all the time’. Participants reported having no energy, ‘running on empty’, as they felt isolated and without support, ‘trying to get support’, from organisations such as their professional society and the statutory board, while family, despite wanting to support, were powerless to do so: ‘My dad … was helpless’.

Participants felt consumed by hopelessness and helplessness, with one stating, ‘You … have absolutely no hope’. The emotional strain was profound, leaving participants feeling ‘helpless, frustrated, very despondent, and very sad about my profession’. The impact extended beyond the individual, affecting employers and family members, who sometimes required support, as one participant recalled, ‘I had to calm her, [the secretary] down’. The anxiety and stress were debilitating, with one participant describing a moment of intense distress. ‘I was rocking in the bath with anxiety and stress’.

The experience was marked by intense shame and embarrassment, with participants feeling ‘like you are the worst human being on the planet’, as you ‘scramble to survive’. The stigma associated with being audited made it difficult for participants to share their experiences with others, with one noting, ‘there’s so much shame around it’. The trauma was akin to post-traumatic stress disorder (PTSD), triggering physical reactions such as ‘go[ing] into a cold sweat’ when encountering reminders of the medical fund. The sense of violation and attack was overwhelming, with ‘The word “blacklisted” feeling like “being shot in the heart”’. For some, the experience was even more distressing than major life events, with one participant comparing it to watching a loved one die: ‘Seven months watching my father die was easier than this experience’. It was, in their words, ‘the most horrible experience I went through’.

The distress ultimately culminated in a sense of defeat, as participants exhausted their options and were forced to concede. For some, this resignation was marked by a sense of detachment, with one participant stating, ‘I don’t care anymore, it’s only money’. However, beneath the facade lay deep-seated anger about the perceived unfairness of the process and its significant financial costs. As one participant put it, ‘That anger will never go away because the process has still appeared unfair’. The experience also triggered profound self-doubt, with participants questioning their professional identity and purpose. For some, this introspection was intense, leading to ‘a big questioning of my professionalism, my field, and even my billing system’.

The participants experienced intense emotional distress, characterised by ‘panic, high anxiety’ that was all-consuming. For some, this was a new and debilitating experience: ‘I mean, I never had depression or anxiety in my life’. The anxiety permeated their daily thoughts, as they struggled to cope with the financial and professional implications: ‘How are we going to do this? How are we going to afford this? Keep the practice going?’ The emotional hurt was evident in their changed demeanour, ‘you never smile anymore’, and their work performance suffered as a result: ‘You’re treating your patient. You’re not focusing on your work properly’.

The participants also felt hurt by the perceived bias and stigma, being labelled as guilty from the outset. They described the experience of trying to reason with investigators who seemed unwilling to consider evidence: ‘You’re giving the evidence to them as logically as you can, and they’re not even looking at it’. This sense of futility was compounded by the fear of reputational damage, with participants anticipating that their names would be ‘drag[ged] through the mud’. As one participant warned, ‘Trying to talk to someone who’s made up their mind, be prepared for them to try and slander your name’.

Participants suffered significant financial losses, with one noting that ‘The financial ramifications are probably the most pronounced’. The burden of exorbitant legal fees, withheld payments and large debt penalties had a significant impact on their practices, particularly for sole practitioners. As one participant observed, ‘We know many of our single colleagues; it was much harder. It almost destroyed their lives’. The financial strain had a profound impact on participants’ well-being and trust in the medical scheme system, leaving them ‘doubtful going forward [concerning] the viability of third-party funding’. Some participants reported feeling drained of their passion and drive, stating ‘Not having that love and drive I once had’.

The participants warned that if the current trends continued, the consequences would be severe and far-reaching. They predicted that practitioners would experience extreme stress, leading to ‘nervous breakdowns’ and even impact their personal lives, resulting in ‘miscarriages and getting divorced’.

The well-being impact on physiotherapists was starkly illustrated by instances of severe health consequences. Although a direct causal link could not be established, ‘one physio[therapist] had a stroke, and the other one had a miscarriage’. The profession was facing attrition, with warnings that physiotherapists would ‘emigrate and stop working in private practice’. Moreover, patients were not immune to these challenges, sometimes facing dire outcomes when forced to pay out of pocket.

To mitigate the adverse effects of audits, improvements to billing education were proposed, including standardising billing courses and introducing them to undergraduate programmes. ‘It needs to be a prerequisite somewhere’, one participant emphasised. A simplified billing system was also advocated for, as the current system was seen as open to interpretation. ‘The billing system is up for interpretation’, highlighted the issue, exposing physiotherapists to billing irregularity audits and divergent understandings, with the medical schemes perceived as ‘trying to find a new loophole to catch us’.

Clearer guidelines and support from professional and statutory bodies were also seen as essential. The professional society was urged to take complete custodianship of the codes and standardise billing practices. ‘The SASP needs to say these are the codes. You have to have this on your system’, participants urged, seeking standardised billing practices. Although physiotherapists are first-line practitioners, they can only refer to themselves as having a special interest and not as a specialist, given the restriction of the HPCSA; ‘I cannot say I’m a specialist in South Africa because of our rules’. Furthermore, participants believed that business education should be integrated into undergraduate programmes to better equip physiotherapists with the knowledge of laws governing their practice, noting that ‘[running a business] has got to feature a little bit more’.

Ultimately, the physiotherapists felt that taking medical schemes to court could provide a platform for them to be heard and liberated, with one asserting, ‘Take them to court and you’ll win’.

The main strength was that the principal author was intrinsically involved and could fully understand participants’ experiences, which is sought after in creating depth in qualitative studies (Malka 2024). However, bracketing was applied to ensure the participants’ views were heard, not those of the principal author, ensuring the attention was on physiotherapists’ experiences (Dörfler & Stierand 2021). Interviews using FGDs and one on one and reflective journaling were used by the author to triangulate and capture detailed, personal stories.

However, there are several limitations. Firstly, participation was voluntary, and many physiotherapists were too scared to come forward. Those who participated may have biased the sample as they were more prepared to speak out. Secondly, the views of medical schemes were portrayed from the physiotherapists’ perspective as described in their interviews and may not be the medical schemes’ perspectives. Thirdly, all participants were audited based on one medical scheme, with only one participant audited using an additional scheme, adding to the contextual constraint of transferability.