Physios clash with medical aids over ‘clawbacks’

Physiotherapists are firing back at medical aid schemes whom they accuse of unethically “clawing back” on claims already paid out to them.

A clawback is an act of retrieving money already paid out to practitioners and, this week, the professional board for physiotherapy, podiatry and biokinetics, under the ambit of the Health Professions Council of South Africa (HPCSA), said schemes were using this practice against physiotherapists in private practice.

“Medical aids are claiming physiotherapists are claiming for procedures that they shouldn’t be and there is an issue around the codes being used for claims. But instead of reporting this on a case to case basis to the HPSCA, schemes are approaching practitioners demanding they pay back the money already paid out from the claim,” said Sibusiso Nhlapho, from the professional board for physiotherapy, podiatry and biokinetics.

The HPCSA said the schemes were engaging in “clawbacks” and were said to be relying on Section 59 (3) of the Medical Schemes Act 131 of 1998 which states: Notwithstanding anything to the contrary contained in any other law a medical scheme may deduct from any benefit payable to such a member or supplier of health service, in the case of:

• Any amount which has been paid bona fide in accordance with the provisions of this Act to which a member or a supplier of health service is not entitled to; or

• Any loss which has been sustained by the medical scheme through theft, fraud, negligence or any misconduct which comes to the notice of the medical scheme.

The HPCSA said it did not condone any criminality among practitioners, but rather than demand outright that they be paid back said that schemes suspecting any act of criminality, such as theft or fraud, should report it to authorities to investigate and prosecute.

On the subject of the wrong use of coding, the HPCSA said that medical schemes were refusing to pay certain rehabilitation procedure codes and were instead, advising practitioners to bill using other codes resulting in a situation where practitioners were encouraged or forced into committing fraudulent acts.

Shainaaz Smile, the HPCSA’s public relations acting manager, said: “We would like to advise practitioners that they should always guard against their Rights as provided for in the Constitution of the Republic of South Africa. Alternatively, practitioners should ensure that they seek legal advice from their lawyers before making any agreements with the various medical aid schemes on matters pertaining to “clawbacks”.”

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August 2020

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