Cimas Online - Together we make a difference

Operations Last date modified: 08/16/2011

An Overview Of The Operations Of The Society

The Society operates as a mutual benefit organisation of members who pool their resources or contributions in order to get assistance from the funds in time of need to help pay for medical costs. This naturally requires a relationship with other bodies in order for it to work.

These other stakeholders comprise ZIMA (Zimbabwe Medical Association), Association of Healthcare Funders of Zimbabwe (AHFoZ), member firms and individual members.

AHFoZ, which represents all registered medical aid organisations negotiates with ZIMA, representing all medical practitioners and various other associations that provide medical services of all kinds (e.g. Radiologists, Pathologists, Physiotherapists, the Private Hospital Association and so on) to set the fees and conditions of operations.

They negotiate a tariff of fees as reflected in the Zimbabwe Relative Value Schedule.

This Schedule of fees and its attendant rules and regulations, determine the fees that are to be paid by medical aid societies and the conditions under which they pay those fees. All medical practitioners and the allied associations that agree to and accept these fees, can be paid on a fee-for-service basis directly by the medical aids.

In other words, the members of a medical aid who utilise the services given by the providers of services do not need to have cash to pay upfront for these services. They accept the provision of services by signing a national claim form which is then passed on to medical aids by the providers for processing and reimbursement. This system is also known as the direct payment facility. Medical Practitioners who wish to enter into the direct payment facility have to be registered with the Health Professions Council in the first instance, and then apply to AHFoZ for a provider number. Over the last few years there has been a change in that for some services provided by direct payment providers, there is a small co-payment required from the member. This co-payment is not claimable from medical aid.

AHFoZ has to satisfy itself the practitioner is registered and has facilities that are of an acceptable standard before issuing a practice number. This number is used by all medical aids for processing claims and making payments to the practitioners.

However, not all providers of services are on this system for a number of reasons. The choice as to whether a provider wishes to be on direct payment rests with that provider and medical aid societies.

Those who opt out of the system are known as 'cash providers'. This comes about because the provider may not be willing to accept the negotiated tariff and wishes to charge more for services.

Alternatively, individual medical aid societies may not be satisfied with the services of the provider through perhaps, misuse and abuse or fraudulent activity by the provider. In these cases, the concerned society will thoroughly investigate the case, put the provider onto a cash basis, and possibly prosecute.

At the present time, over 90 percent of general practitioners are on the direct-fee-for-service payment. The majority of specialists and related associations such as the private hospitals and ancillary providers also operate on this system. Some providers prefer the cash system as they may be experiencing cash flow problems.