The Sunday Mail
>> Cimas, physicians cross swords
>> Double whammy for medical aid members
>> Govt urged to intervene
A nurse in a room where medicines are prepared and collected – Picture by Kudakwashe Hunda
Darlington Musarurwa and Africa Moyo
MEDICAL services company Cimas is locked in a potentially damaging and brutal wrangle with an association representing the interests of physicians and medical services group Corporate24, a development that could prejudice subscribers.
The clashes have been occasioned by Cimas’ recent unilateral move to refuse to honour claims from physicians who would have failed to “renew” their Association of Health Funders of Zimbabwe (AHFoZ) numbers by June 30, 2015.
This has prompted the National Physcians Association of Zimbabwe (NaPAZ) to demand cash upfront from Cimas members.
Similarly, Cimas has also controversially decided to stop honouring claims from Corporate24 over four disputed claims, notwithstanding the fact that the latter caters for more than 30 000 Cimas Medical Aid Society members.
In essence, most Cimas subscribers will have to pay cash for medical care or otherwise use facilities that Cimas favours.
Statutory Instrument 330 of 2000 and SI 35 of 2004 make it illegal for medical aid societies to direct their members to particular service providers.
The developments are reminiscent of the previous dispute pitting Cimas on one hand, and QV Pharmacies – a subsidiary of CAPS – and Lancet Laboratories in 2012, where the medical aid society decided not to process claims from the two entities.
It took the intervention of the Competition and Tariffs Commission for sanity to be restored.
Physicians take umbrage
Last week, physicians indicated that they were willing to engage Cimas “in a fruitful manner so that an amicable position can be found”.
In a letter dated June 30, 2015 by NaPAZ president Dr Christopher Pasi and secretary-general Dr Ngwende, the association notified the country’s major medical centres that effective July 1, Cimas patients would have to pay cash upfront.
“Please be advised that with effect from 1st July 2015, all CIMAS patients seen in the rooms or admitted by physicians will be required to pay cash upfront. This unfortunate situation has been brought about by the position communicated by Cimas that they will not pay out any claims submitted from 1st July by doctors who fail to ‘renew’ their AHFoZ numbers by 30 June 2015.
“The concept of ‘renewing the AFHoZ number’ is something that we strongly disagree with. Our position has been communicated to Cimas and other stakeholders . . .” reads part of the letter seen by The Sunday Mail Business.
The case with Corporate24 is eerily similar to other Cimas disputes, as the medical aid society is accused of “generating” a dispute over four disputed claims in order to stop processing claims from the group.
Again, this is considered a smokescreen meant to force Cimas members to resort to Cimas-owned facilities.
On June 25, 2015 Cimas Medical Aid Society MD Mr Rodrick Takawira wrote to Corporate24 advising them of the termination of their relationship on the pretext that the latter had submitted dubious claims.
“Following our meeting in Dr Gwatidzo’s office with Corporate24 representatives Sandra Nyamimba, Mr Chidavaenzi and Regina, the society has been forced to place all your practices on cash with immediate effect.
“The reason is because our relationship with your practices is based purely on trust and that trust has been broken, we find ourselves with no choice but to terminate the relationship. We will continue investigating your claims in retrospect and we will recover where we have been prejudiced.
“Please note that this is not a prohibition from seeing our members, but if you see them, charge them cash and give them a completed, stamped and signed claim form with the receipt for reimbursement by the Society,” said the letter.
It is believed that the decision to pass on the responsibility of communicating such an inconvenient arrangement to Corporate24 is meant to enable the Society to tactfully wriggle itself out of a tight spot.
Corporate24 said it would take legal action should the allegations turn out to be false.
Said Corporate24: “Your letter alleges that we are involved in fraudulent activities in dealing with Cimas because of four claims which had some irregularities. The quantum
aken is at very strong variance with the claims involved and the standard procedure of dealing with queried claims. “Cimas set precedence of how these issues have been resolved over the years and surprisingly in this instance there has been a total shift.
“Corporate 24 has taken your allegations of fraud seriously and would like to institute investigations into the matter urgently to enable us to correctly inform our board, clients and key stakeholders. In this light, may you kindly furnish us with minutes of the meeting chaired by Dr Gwatidzo with our team at your offices to enable us to expedite this process.
“Also may you kindly give us physical copies of the claims involved as they were retained in Dr Gwatidzo’s file. We are of the opinion that a different approach to exhaust all channels to resolve this matter would have been mutually beneficial to avoid unnecessary inconveniences to your membership.
“Since you have stated that you are putting Corporate 24 under investigations and would like to recover any prejudices to Cimas.
“We gladly advise you to urgently convene a meeting at our level as the organisation’s leadership so that we agree on some key modalities of this exercise. Corporate 24 if found to be wrongly accused will also not hesitate to claim what is due to us at law. Currently your system has challenges that has been prejudicing us huge figures for a long time and all we have been doing is engage.”
Patients suffer
Ultimately, it is ordinary members that get the short end of the stick.
The decision to charge Cimas medical aid card holders cash represents a double whammy for paid-up subscribers who are still smarting from a more than 30 percent increase in contributions.
Tariff increases are however only affecting individual private hospital package and individual Medexec package which are under-performing “such that claims submitted on the packages were surpassing contributions being collected, thereby prompting the upward review”.
Corporate accounts are not affected.
The adjustments were effective from July 1, 2015. Efforts to get a comment from Mr Takawira were not fruitful as he was reportedly out of the country.
Cimas referred this paper to the company’s group operations executive Mr Vulindlela Ndlovu.
Said Mr Ndlovu: “Our members are accessing any provider of their choice without any restrictions. However, the society does require, where claims for specialist physicians are concerned, that, as is the normal medical practice, the member should have been referred to the specialist by a general practitioner or primary healthcare facility. Cimas does not employ specialist physicians.
“The Cimas drug benefit is in place. “Cimas has only suspended the online drug facility that was being abused by some pharmacies and members with a view to putting in place measures to prevent such fraud. As an interim measure the society is reimbursing its members twice a month for all cash claims until the drug payments online facility is restored.
“Our licence does not allow us to dispense drugs to people that have not been seen by doctors at our clinics.”
Some of Cimas members who spoke to The Sunday Mail Business expressed fear about the sum effect of this.
“I am Cimas member on the private hospital plan and yesterday (Thursday) I went to a medical institution in town to be attended to.
“After I was attended to, I got a prescription which I took to Cimas but they refused to give me the medication saying they do not accept prescriptions from other practitioners.
“They told me to get examined by their own doctors so that I could get medication. But imagine that this is a sick person they are tossing around.
“I ended up going to another pharmacy to get the medication. This ill-treatment comes almost a month after Cimas said it no longer covers drugs. I think it is unfair from Cimas because I pay my subscriptions every month.
“When I went back to office, I phoned them and the person I spoke to was not even polite. I was later referred to marketing but I cannot remember the name of the man I spoke to, who was also impolite,” said a member who elected to remain anonymous for fear of victimisation.
Shades of 2012
The current dispute mimics the crisis that plagued the sector in early 2012 when Cimas announced that its members were expected to pay cash for services at Lancet Laboratories and QV Pharmacies owing to what the society said were operational challenges the medical aid society was facing with the two service providers.
In October 2012 the Competition and Tariffs Commission conducted a full-scale investigation into alleged “restrictive practices” by Cimas Medical Aid Society.
Cimas was accused of forcing members to pay cash at Lancet Laboratories or alternatively use their membership cards In 2011, Netstar Ambulances had lodged a complaint with the CTC against Cimas for refusing to honour claims for services rendered. Netstar however decided not to proceed with the matter.
For the year ending December 31, 2014, Cimas reported that its membership growth had remained flat at 203 481 members.
Attendances at Cimas Medical Laboratories were flat relative to a year earlier.
But the business posted a surplus of US$4,3 million from US$5,5 million in the prior year weighed down by writedowns in respect to non-performing contribution receivables as some of receivables as certain member firms had not serviced their accounts for lengthy periods.
Non-medical aid activities contributed more than 68 percent of the surplus.
