Cimas puts in place measures to expedite processing of drug claims

Cimas Medical Aid Society has put in place measures to ensure that all drug claims are processed expeditiously, following its decision to suspend its online drug payment facility as a result of an upsurge in fraudulent claims.

In addition, claim forms are being collected twice a day from designated collection points. The capture of the data on these forms is being given priority.

A Cimas spokesperson said the inconvenience to members of suspending the online facility was regretted but unavoidable due to the fraudulent activity which had seen drug claims increasing by more than a million dollars in the first three months of this year, when compared to the same period last year.

"During the first quarter of 2014 we spent $2,2 million on drugs for 205 000 beneficiaries. In the first quarter of 2015, with a reduced membership of 202 000 beneficiaries and reduced cost of drugs, we incurred a $3,4 million drug bill. That is a difference of $1,2 million in just three months, or an increase in drug costs of 54 percent," he said.

 "Our online drug facility has been of great benefit to our members. However, the efficient functioning of this facility is premised on several assumptions, including that members are careful and vigilant with their prescriptions and regularly check their statements to verify the drug claims on them and that pharmacies verify the identity of members accessing drugs from them," the spokesperson said.

He said there was an instance of fraud recently when a woman used a stolen Cimas membership card to buy the same drugs from three different pharmacies. When the police asked her what she intended doing with them, she said she intended to sell them in Mbare.

She had already made an unsuccessful attempt to obtain the drugs from another pharmacy using the stolen Cimas card but disappeared when she was unable to produce an identity card and the pharmacist phoned Cimas to ask whether he could accept the claim.
When arrested she was found to have numerous medical aid cards from different medical aid societies.

However, that is not the only type of fraud that Cimas is up against. There have been discrepancies between the online claims made by some pharmacists and the hard copy prescription forms.

"Drug claims submitted by pharmacies electronically do not always tally with the physical hard copy of the prescription," the spokesperson said.

"There is also the problem of some members allowing relatives or friends to use their card to buy medicines.
 
"We had tried to counter this by issuing membership cards with the member's photograph on them. However, we have to rely on pharmacists to check whether the person purchasing the drugs looks the same as the person pictured on the membership card and to check their national identity cards. It seems clear that not all of them do so," he said.

He added that in the circumstances Cimas could no longer continue to lose members' funds through various types of fraud. That was why reluctantly it had to suspend the online drugs facility.
He said arrangements could be made for those on pre-authorised chronic medication to access their monthly supply of drugs from approved pharmacies. There were already arrangements for this in respect of patients on chemotherapy, antiretroviral drugs and dialysis.
Cimas was in the meantime exploring what measures could be adopted to make the online facility more secure, so that members could enjoy its convenience without their funds being placed at risk, he said.

He said members received a text message notifying them of their online drug facility transactions but few notified Cimas when they received a message about a transaction they had not made.

"I don't think most of our members realise that it is their funds that are at risk and that fraudulent claims reduce the amount of money that is available to pay their legitimate claims," the spokesperson said.