IT is a pity that only about 10% of the population in Zimbabwe is covered under medical aid societies, leaving the majority of the populace depending on out-of-pocket payment for medical attention.
The medical aid industry is not performing as expected and for ages has thus shown stagnancy, leaving one to wonder why it is that way. Despite many players entering this industry, membership remains sluggish as people seem to lack confidence in medical aid societies.
There seems to be ceaseless acrimony between service providers and many medical aid societies, the root cause being non-payment of dues, delayed payment and bully behaviour. Many medical practitioners feel they are being strangulated by the egregious behaviour of the health funders who want to dictate everything in the medical industry.
Service providers are treated as if they are of no importance and relevance at all, yet they are the protagonists in the industry.
Patients should know why many service providers reject their cards despite their schemes being supported by United States dollars.
It is the poor management of their schemes which results in them being denied medical attention because the behaviour of the funders does not change despite one contributing in US dollars. You hear of misuse of funds by some health funders and recently, Cimas was in the Press for wrong reasons when the chief executive officer was accused of embarking on an unviable expansion both locally and abroad, awarding contracts to friends and siphoning money through renovation of clinics at unsustainable costs, while arranging loans for top managers which cost the society more than US$10 million.
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Cimas clients should question where all that money is coming from when they are being denied medical attention by service providers who claim that medical aid societies are perennially defaulting payment.
I was flabbergasted when the same Cimas could not honour claims because ICD-10 Codes (International Classification of Disease 10th Revision) were missing.
Imagine offering emergency service to a bleeding patient who gets sutured and rehydrated using my own resources and then no cent is paid because of the so-called ICD-10 codes, yet all the details, diagnosis and management are crystal clear.
This is daylight robbery that should not be allowed to continue under our very noses.
The regulator should be firm when such complaints are raised because some of the actions of health funders are retrogressive to our quest to achieve universal health coverage. This is the work of our so-called esteemed medical aid societies which capitalise on Pareto optimality to enrich themselves.
First Mutual is not omitted in the line of fire as it plays dirty tricks to evade payment. It rejected claims merely because our claims manager had put US$30 as initial consultation.
Instead of just correcting, the health funder saw it fit to reject the claims, yet service was rendered and the same medical aid society dreams of us accepting its clients without co-payment.
Throwing away all such claims is tantamount to sabotage that should be condemned by all sober-minded persons.
Cellmed has also come in with its bag full of tricks to evade payment. As for Ngezi Platinum clients, medical practitioners have been instructed to claim only US$5 as consultation, a figure which is a natural deterrent to accepting its medical aid card holders.
Imagine sending a US$5 claim form to the medical aid and waiting for the money to be paid after 60 days, that is preposterous! The same medical aid society has denied registration to new applicants who want to be on its platform, especially those in Ngezi, a development which saw Ngezi-based doctors complaining to the Competition and Tariff Commission on August 8, 2023.
Fair practices are what everyone desires if national health service delivery is to improve.
The country needs dedicated players in the health fraternity, not opportunists. A strong health delivery system is possible through six building blocks of service delivery, financing, governance, medicines, informatics and health workforce!
- Johannes Marisa is president of the Medical and Dental Private Practitioners Association of Zimbabwe. He writes here in his personal capacity.