The Sunday Mail
Livingstone Marufu
GOVERNMENT will this week sit down with Cimas Medical Aid Society and Corporate 24 and try to decisively settle their 19-month dispute over unpaid medical claims.
Industry regulator, the Ministry of Health and Child Welfare, believes the recently completed forensic audit by Grant Thornton South Africa conveniently gives it the muscle to bridge differences between the two warring parties.
Last week, Health and Child Care permanent secretary Dr Gerald Gwinji said the mediation process is expected to take place this week.
“We are planning to meet this week or the beginning of next month. The forensic audit will discuss about the outstanding claims, direction of the claims as to how the payments are going to be made and the cash payments issue, among other sticking points you had known for long. All the parties have had a lot of discussions and there are a lot of things that were being said but we needed further documentation and definite proof to be put on the table so that we can discuss with the two parties on matters affecting their relationship.
“We are confident that we will reach an agreement this time as their arguments are very articulate and are structured in a transparent manner which is very understandable to all parties.
“The discussions will go on smoothly as we now have the real samples to the claims that were made, previously we didn’t have concrete linkages to the claims,” said Dr Gwinji.
It is understood Cimas and Corporate 24 are willing to negotiate after the audit report “clarified some sticking points”.
Resolution of the dispute could help lessen the burden of more than 30 000 subscribers who rely on the medical facility’s services. Corporate 24 is owed over US$500 000 in unpaid claims since June 2015, but the financial prejudice over the 20-month period is estimated at US$2 million considering the fact that prior to the ban, Corporate 24 was claiming between US$100 000 and US$120 000 every month from Cimas alone.
As the dispute escalated, Corporate 24 has had to resort to recover money directly from patients in order to ensure that their business remains sustainable.
Similarly, Cimas, through circulars to its subscribers, has been urging its members to pay cash and submit claim forms for refunds.
The arrangement has essentially collapsed the medical insurance scheme where patients who hold valid medical aid cards have to be attended.
Government, which has been trying to restore normalcy to the sector, last week cautioned that it was not trying to implement recommendations of the report, but to use it to bring the two parties together.
“The audit report is not for us to implement the recommendations made by Cimas in terms of their relationship with Corporate 24 but to inform us what they thought were the anomalies and what they expect to be done, then we see how best we can reach an agreement with concerned parties.
“What we expect from Cimas is to share this very same audit report with their counterparts and then we expect Corporate 24 as an entity to put their case on the table and say with regards to this no (things didn’t happen that way ) and with regards to this no. Now these are legal entities only connected by this issue, one is not superior to the other and one is not important than the other,” said Dr Gwinji.
Corporate 24, which maintains a database of over 24 000 members and their beneficiaries, reported the matter to the regulator in July 2015 after Cimas stopped processing their claims on allegations of fraudulent claims.
Government has however been trying to make the parties comply with the law to the extent that in May last year, Cimas was given an ultimatum to process all the outstanding claims or risk losing its licence.
The High Court barred the move pending the mutual resolution of the issue by the companies. But Corporate 24 contends that the forensic audit was “unlawfully used by Cimas as a tool to deny us payment of claims for services rendered to its membership by ourselves”. Contentious issues surrounding the audit also relate to the unilateral appointment of auditors by Cimas, the terms of reference given to the auditors by Cimas,the methodology, selection criteria of the claims investigated, the size of the claim sample as a function of the total claims, patient rights to confidentiality, including the standing laws guiding medical aid operations in Zimbabwe.
There were reports that Grant Thornton faced stiff resistance, particularly from some subscribers who felt that their enquiries were an intrusion into doctor-patient confidentially.
Corporate 24 also didn’t make any contributions that were used to compile the report.
Overall, it is believed that the two warring parties are willing to settle.
