Technological innovations can ease medical aid societies, service providers tiff

Medical Aid Societies

Johannes Marisa
HEALTH service providers are crying foul about Medical Aid Societies (MASes) accusing them of iniquity. The same has happened with MASes that blame practitioners for improper conduct when dealing with their clients. The major reason highlighted by service providers is that of non-payment of claims. The excuses given by MASes are too many.

Some of them include missing claim forms, inconspicuous papers, ineligible signatures, wrong tariff codes to mention a few. I got the shock of my life last week when I received a meagre payment of $497 from one prominent MAS, a figure which does not translate to US$3.

This is the main reason why many practitioners snub medical aid card holders. Technological innovations should come in to expedite numerous processes that involve service providers and MASes.

The Association of Private Medical and Dental Practitioners of Zimbabwe had a short meeting with Tres Group International, an organisation that provides healthcare risk advisory and schemes administration services in the region. The organisation created a healthcare instant payment platform which will see medical practitioners being equipped with smart point-of-sale (POS) machines that will enable instant payment to medical service providers.

This will eliminate paper claim forms as well as forward pricing with a positive effect on out-of-pocket expenses. I liked the idea of fraud mitigation because the smart POS has fingerprint facilities, does facial recognition and has an iris scanner. If that innovation is adopted by both medical practitioners and MASes, the year 2022 will eliminate the acrimony between the parties. We will witness harmony in the medical industry sooner than later.

The MASes are regulated under the Medical Services Act (Chapter 15:13) that deals with both the registration and cancellation of medical aid societies.

Medical practitioners have their respective councils that register them while the Health Professions Authority of Zimbabwe (HPAZ) is the supreme authority that plays an oversight role on all medical institutions. HPAZ also protects public interest.

It is, therefore, illegal to operate a medical institution without a licence in Zimbabwe. Different practitioners deal with MASes, among them are medical doctors, dentists, scientists, physiotherapists, occupational therapists, pharmacists, nurses and medical psychologists.

The tiff between service providers and MASes has been going on for years and it is unpalatable. This has worked much to the detriment of smooth health delivery with patients bearing the brunt of the resentment.

Many patients think that medical practitioners are the ones to blame for disjointed service yet the health funders have their ills on health service delivery as well. Other than the issue of payments, there are other anomalies that infuriate service providers:

  • Dictation to service providers — Many practitioners especially general practitioners get infuriated when MASes refuse to honour some medical investigation claims like computed tomography scans. I wonder if MASes think the doctors are not qualified enough to determine if a patient needs such a scan or not. Such kind of thinking that belittles well-trained practitioners will not help alleviate the acrimony but will add insult to injury.
  • Unilateralism on tariff gazetting — MASes have often been accused of unilaterally coming up with tariffs that suit them. In 2015, the Zimbabwe Medical Association (Zima) agreed with MASes on particular tariffs such as those for initial consultation and subsequent visits. Unfortunately, the agreed tariffs were not implemented by MASes and the tension persisted.
  • There is no logical negotiation that materialises when one acts as a superpower and manipulates everyone. Service providers have often responded by further flexing their muscles in order to remain afloat especially during this COVID-19 era where the costs of running clinics, surgeries or hospitals are spiralling.
  • Diverting patients to preferred practitioners — Many service providers have complained about some MASes that unethically divert patients to their preferred practitioners. Some threaten clients that they will not honour claims from practitioners they did not recommend, which is not only barbaric but also treacherous.
  • MASes have also raised some issues which I think can be alleviated by technological innovations if introduced. These issues include:
  • Fraudulent claims — There are cases of false claims that are purportedly sent to MASes yet some of the patients were never seen at the medical centres, a conduct which no one condones. That practice should stop if ever it was there.
  • Overcharging patients —The issue of overcharging has been raised several times, but has gained prominence during the COVID-19 era. While those not on the ground might not realise how expensive COVID-19 management is, the practitioners will argue that the cost of sundries and medicines is horrendous.

Oxygen cost for desaturating patients is unbearable, considering that some patients may require at least six oxygen cylinders in one day. Service providers cannot remain viable when treating COVID-19 patients with some MASes taking two full months to pay yet cash is needed to stock drugs, sanitisers, personal protective equipment and for salaries, including risk allowances.

Let us all embrace technology and innovation. Service providers will not tolerate bullish behaviour by MASes.