The decision by Cimas Medical Aid society to remove Family Medical Clinic of Masvingo from its direct payment system and to refuse reimbursement for treatment at that clinic by its members has triggered an investigation by the Competition and Tariff Commission.
The competition commission is legally empowered to become involved because Cimas operates its own clinic in Masvingo city and so the possibility exists that the Cimas move could have been to restrict competition. The commission is also obliged to investigate any complaint where there could be a possible attempt to limit competition.
However the competition commission accepts that Cimas members can use other private clinics in Masvingo with their cards.
Cimas does occasionally deregister a clinic, service provider or pharmacy, and might even refuse to reimburse members who use these, when it believes that inaccurate claims are being made. A dispute with one of the several private emergency clinics in Avondale, which saw Cimas refusing to pay on claims, ended up as a civil court case. But in 2010 a row between Cimas and a medical laboratory reached the Health Ministry which felt Cimas was being unfair.
The Masvingo probe was announced in the Government Gazette under General Notice 2792 of 2022 published last week.
“It is hereby notified, in terms of section 28 of the Competition Act that the Competition and Tariff Commission has commenced an investigation into an alleged restrictive practice, as defined in terms of section 2 of the Act, by Cimas Medical Aid Society,” reads the notice.
Section 28 of the Act empowers the commission to undertake investigations into possible restrictive practices.
The notice carefully lays out the basis for the commission being able to act. “It is alleged that Cimas deregistered Family Medical Clinic from the New Health 263 direct payment system. It is further alleged that, apart from the deregistration of Family Medical Clinic from the New Health 263 direct payment system, Cimas is neither reimbursing its members nor honouring claims for treatment of its members at Family Medical Clinic.
“Deregistration of Family Medical Clinic from New Health 263 direct payment system resulted in Cimas members having to pay cash for treatment at Family Medical Clinic. The commission established that Cimas is a medical aid society which also operates a clinic in Masvingo, Cimas Clinic, so allowing the investigation to take place.
From the notice it appears that either the clinic or a Cimas member has raised a complaint, obliging the commission in these circumstances to investigate.
“Cimas is alleged to be indirectly referring its members to its own facility, Cimas Clinic. The Commission has preliminary concerns that the alleged practice may result in members’ choice of healthcare being limited to Cimas Clinic and other healthcare providers preferred by Cimas where their medical aid cards are accepted,” the notice read.
Many medical aid societies, including PSMAS and Cimas, the largest two, operate their own facilities in the growing trend towards managed health care. Members can use these society-owned facilities without shortfalls but are reimbursed at a standard rate, or if the service provider is on direct payment that provider is paid at the standard rates. If the service provider charges more than the standard rate this creates shortfalls. – The Herald
