Cimas puts in place measures to curb drug facility abuse

Cimas Medical Aid Society is putting in place measures to prevent abuse of its online drug facility that was suspended in May. It envisages the facility being restored by the end of September.

However, not all pharmacies will have the facility. Those pharmacies that were found to have submitted fraudulent online claims would be excluded.

Speaking at the Cimas Medical Aid Society Annual General Meeting (AGM) in Harare on Wednesday, Cimas Group IT executive Roderick Takawira said the society had engaged a vendor to come up with a secure system involving a one-time personal identification number (OTP) to end the abuse of the online drug facility.

He explained that, following the discovery of an individual fraud by a woman who was using other people's cards to buy drugs from pharmacies, investigations showed that many pharmacies were changing the quantities of drugs dispensed or even adding ones that had not been dispensed when submitting the online claim.

He said the success of the new membership  cards with the member's photograph on it in preventing fraud depended on pharmacists acting as gatekeepers and checking that the person presenting the membership card was the person in the photograph. Not all of them were doing that.

Not only that but some pharmacies were themselves engaging in fraud by submitting claims for drugs that had not been dispensed.

"So far our investigations have revealed that over 80 percent of pharmacies online claims checked had either quantities changed or extra drugs included," he said.

"The gatekeepers had gone rogue," he said

The fraudulent claims are believed to have been largely responsible for an increase in claims costs in the first few months of this year that Mr Takawira said was unprecedented.

Cimas Medical Aid Society chairman Mordecai Mahlangu told members of the society that faced with evidence of such extensive fraud, the society's board had felt there was no option but to  suspend the online facility to protect members' funds, while it sought ways of preventing such fraud.

Mr Takawira said the more secure system envisaged involved the sending of the one-time PIN to the member's registered cellphone. The member would give the pharmacist the number to enter in order to send the online claim. The PIN would only be valid for 10 minutes. The claim would have to be sent, therefore, while the member was still there.

He said this system would be ready for testing in the next two weeks or so. It was estimated that the online facility would be in use again by the end of the third quarter of the year.

Interim arrangements had been made to enable cancer patients and those on anti-retroviral drugs to access their drugs without having to pay for them in advance. Members on chronic medication could obtain them from Cimas clinics.

Measures had also been put in place to speedily process drug purchase refund claims.

Mr Takawira said the medical aid society was making use of a data analytical expert to assist in analysing data further to identify more specific trends and incidents of fraud and abuse. A forensic audit team was also being brought in to investigate the anomalies, starting with pharmacies.

Mr Takawira also explained the increase in contributions for those on the Private Hospital Scheme, Medexec scheme and pensioners' scheme had been necessitated by benefits payments for these members exceeding their contributions. The increase would still only mean that what was paid out equalled what was received, which meant there was nothing over for administration costs.

In order to further reduce claims costs without increasing subscriptions further, he said the society was looking at introducing stand-alone packages for dental, optical and drug benefits as well introducing limits on the number of visits to general practitioners and specialists and introducing pre-authorisations for some procedures.

In his chairman's statement in the annual report Mr Mahlangu also alluded to the increase in the claims costs.

"There has been a marked increase in claims costs in the last few months and this undoubtedly places your society in the most invidious position that we have faced in the last six years. Our claims costs have increased at a time when there was a marginal increase in membership in 2014 and a decline since January 2015," Mr Mahlangu said.

The surplus generated in 2014 was $4,3 million, compared to $5,5 million the previous year. The surplus had enabled the society to grow the claims reserves to 8,7 weeks form 8,1 weeks.

"It remains a strategic objective of your society to achieve the 12 weeks reserves as per best practice," he said.

Welcoming members to the annual general meeting, Mr Mahlangu revealed that one of the society's members had made an urgent application to the High Court that morning seeking a court order to postpone the annual general meeting.

He said the court had dismissed the application and confirmed that an annual general meeting could only deal with matters on the agenda where 21 days' notice of these matters had been given.