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Business Reporter
CIMAS Medical Aid Society is working on measures to prevent abuse of its online drug facility that was suspended in May and targets to restore the facility by end of September.
However, not all pharmacies will have the facility, the firm said, and the pharmacies that were found to have submitted fraudulent online claims would be excluded.
Speaking at the Cimas Medical Aid Society Annual General Meeting in Harare on Wednesday, Cimas Group Information Technology executive Mr Roderick Takawira said Cimas 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 said that following the discovery of an individual fraud by a woman who was using other people’s cards to buy drugs from its 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 them in preventing fraud depended on pharmacists acting as gatekeepers and checking that the person presenting the membership card was the person in the photograph.
While not all pharmacies observed the security requirement, others 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 gate-keepers 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 chairman Mr Mordecai Mahlangu told members of the society that faced with evidence of such extensive fraud, the board felt there was no option, but to suspend the online facility to protect members’ funds, while seeking ways to prevent such fraud.
Mr Takawira said the more secure system envisaged involved sending one-time PIN to the member’s registered cellphone. The member would give the pharmacist the number to enter 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 is still there.
He said this system would be ready for testing in the next two weeks. It was estimated that the online facility would be in use again by the end of the third quarter of the year.
Interim arrangements have 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 the drugs 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, 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 the chairman’s statement in the annual report, Mr Mahlangu also alluded to the increase in the claims costs.
The surplus generated in 2014 was $4,3 million, compared to $5,5 million last year. The surplus enabled the society to grow the claims reserves to 8,7 weeks form 8,1 weeks.
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