Medical insurance under serious scrutiny

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Darlington Musarurwa and Livingstone Marufu
THE haggling between Cimas Medical Aid Society and hospital services group Corporate 24, which has seen the latter engage debt collectors to recover more than US$500 000 in unpaid claims directly from medical aid subscribers, is raising the spectre of an attack on the medical insurance business.

It is feared that if Corporate 24 successfully recovers the half-a-million that it is owed through debt collectors, other medical service providers will follow suit, with medical aid subscribers being the ultimate losers. Overally, doctors and other medical service providers are owed in excess of US$220 million, according to figures from the Zimbabwe Medical Association (ZiMA), with Public Service Medical Aid Society (PSMAS) carrying the bulk of the debt at US$180 million.

The remainder is owed by other medical aid societies. Last year, Cimas clashed with the National Physicians Association of Zimbabwe (NaPAZ), the Hospital Doctors Association of Zimbabwe and the Retail Pharmacists’ Association of Zimbabwe (RPA) over its reluctance to honour some of the claims, but the dispute with Corporate 24 has been the most brutal.

In May last year, Government, through the Ministry of Health and Child Care, threatened to cancel Cimas’ operating licence if it did not follow through provisions of the law to settle outstanding claims from the hospital group, but the medical aid society managed to get a reprieve after the High Court barred Government from doing so pending the finalisation of the dispute.
Cimas generally views the Ministry of Health as an unfair arbiter.

Even though Cimas got the reprieve, Government feels that this does not allow the Society to disregard the provisions of the law.
The law makes it illegal for valid medical aid holders to pay cash upfront to service providers. The Society is however, digging in.
In a circular to its members on April 21, 2016, Cimas indicated that Corporate 24 is still on cash.

“Please note that the current position is that Corporate 24 is still on cash. Cimas is however, committed to paying Corporate 24 in respect of all outstanding claims as of March 28 2016.

“As our communication in August 2015, the decision to put Corporate 24 on cash was prompted by operational challenges that Cimas Medical Aid Society was experiencing with Corporate 24. Direct payment to Corporate 24 will be reviewed upon the conclusion of a forensic audit that is currently underway,” said Cimas.

It is believed that the tiff between the two key medical service businesses was precipitated by allegations of fraudulent claims.
It was the same allegations that led to the dispute with NaPAZ, RPA and hospital doctors. Grant Thornton of South Africa has been engaged to do the forensic audit, and this has again raised discomfort among members of the Society as they feel that their subscriptions will be used to fund the exercise.

They feel that they are being used as pawns in the two groups’ gamesmanship. Recent reports indicated that the engagement of Grant Thornton, which is understood to have been largely unfamiliar with the local terrain, was not without its hurdles, as some members that were called for interviews during the audit process were discomforted by the release of their medical files — which are generally governed by doctor/client confidentially — to third parties.

A draft report of the audit has been completed and will soon be sent to the regulator.

“Our forensic auditors have issued us with the draft report which they require us to review and tender our comments. Once we have submitted these comments they will issue a final report.

“You will notice that there is only one provider that we had a challenge with and the reason for our decision was very simple: we detected unacceptable conduct from that provider which was prejudicial to the Society and its members.

“It is therefore an isolated case that we are dealing with . . .
“A forensic audit is not something that can be rushed as there are a number of aspects that must be looked at. It has to be done carefully and with diligence to ensure credibility in the findings,” Cimas said in responses to The Sunday Mail Business last week.
The Society also accused this publication of making “unsubstantiated claims” and casting it in bad light.

But as the unpaid claims continue to mount, Corporate 24, which feels bound by the strictures of the law to attend to medical aid card holders, is now resorting to recover the money directly from Cimas members.

Last week, Corporate 24 claimed that it had been prejudiced of more than US$2 million since June last year.

“The decision to recover money from members was one of the toughest decisions that we had to make. Carrying the burden of continuously giving service without knowing when you will be paid had become unsustainable.

“We tried to wait for resolution but there seems to be no solution anywhere near. We have to pay for drugs, consumables, salaries and reagents to continue to run the business.

“Going forward, we will continue assisting Cimas clients without demanding cash upfront on condition that if the claim cannot be settled within 60 days we will seek recourse from the member who will have to pay us and claim for refund from Cimas,” said Corporate 24 last week.

Compromised arbiter
It is felt that Government cannot decisively deal with some of the disputes such as those between Cimas and Corporate 24 as PSMAS is accused of worse infractions. PSMAS owes service providers more than US$180 million, but through Statutory Instrument 77 of 2015, the Society’s property cannot be attached.

Zima secretary general Dr Shingi Bopoto says doctors and service providers have come up with a number of debt collection methods to recover their money.

Debts have soared to US$220 million.
Dr Shingi Bopoto, the Zimbabwe Medical Association (Zima) secretary general, told The Sunday Mail Business that doctors have come up with a number of debt collection methods in a bid to recover their money.

“We have devised a number of methods to collect debts from the medical aid societies which include suing the medical aid societies — serving them with summons advising them that if they don’t pay such an amount we will take the matter before the courts.

“The other method which our doctors are using involves going before courts with those medical aid societies — in this area we are very happy as most of our doctors are winning their cases.

“Some doctors are engaging patients directly to come up with payment plans of how best they can settle their debts.

“As an association we are engaging the Government to help us settle the PSMAS debt. As we speak, we are working out something with the Finance and Economic Development Ministry to make sure we get something.

“On the other hand, we are engaging the Health and Child Care Ministry to ensure that all regulations that govern medical aid societies are enforced,” explained Dr Bopoto.

Government is in the process of establishing a regulatory board that will superintend medical aid societies and ease tensions between healthcare funders and service providers. The Medical Aid Regulatory Board could be appointed this year if Parliament passes the enabling law as recommended by the Health and Child Care Ministry.

Presently, the ministry oversees both parties and arbitrates disputes.  This arrangement has, however, failed to end the stand-off between service providers and medical aid societies. There is also a conscious attempt to close loopholes within the law that has led to the exploitation of medical aid subscribers. The Sunday MAil

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