Elederly patient in a hospital getting an insurance claim

SINGAPORE: The Ministry of Health (MOH) is stepping up monitoring of inappropriate MediShield Life claims and will “not hesitate to act against the small minority of doctors who are found to be repeatedly non-compliant despite warnings. Repeat offenders may have their accreditation status under the MediShield Life and MediSave schemes suspended or revoked.”

MOH said this in a press release on Tuesday (Oct 10) about its efforts to manage healthcare costs. It set up the Claims Management Office (CMO) in 2022 to guide appropriate MediShield Life claims and guard against inappropriate claims as part of the effort to manage healthcare costs.

Before the CMO’s establishment, MOH was already conducting regular surveillance audits of MediShield Life claims. With the CMO in place, MOH has extended its oversight through claims adjudication.

Since it began adjudicating MediShield Life claims in October 2022, 32 cases have been processed. Of these, 29 cases, involving 10 doctors, were identified as inappropriate claims. Common errors included incorrect surgical codes, over-servicing, and submission of claims not covered by MediShield Life.

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Providing clarity through claims rules

To provide clarity to medical practitioners and patients, claims rules have been introduced to define what constitutes an appropriate MediShield Life claim. These rules empower healthcare professionals to better advise their patients on claimable procedures, safeguarding them from unnecessary medical risks and financial burdens associated with medically unnecessary treatments.

Speciality-specific claims rules

Speciality-specific claims rules are developed through collaboration with public and private sector specialists in relevant medical fields. These rules are based on evidence-based literature, clinical practices, and cost-effective guidelines.

The first set of claims rules for gastrointestinal endoscopy was introduced in August 2022, with two additional sets for ear, nose, and throat, and cardiology released in September 2023.

Adjudication for greater scrutiny

Claims identified as highly likely to be inappropriate undergo further scrutiny through adjudication. An independent panel, appointed by the MediShield Life Council and comprising both public and private sector specialists, assesses these claims for compliance with MOH’s published rules.

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In cases where a claim is found inappropriate, the medical institution and/or doctor are required to rectify and refund the inappropriate portions of the claim without affecting the patient’s financial situation. Doctors have a 30-working-day window to appeal with new evidence.

Safeguarding patients’ interests

To safeguard patients from unnecessary medical risks and financial burdens, MOH advises against claiming procedures not covered by MediShield Life, such as cosmetic surgeries. Patients can also check the MOH website for the cost of various procedures.

 

Supporting doctors

In addition, MOH has launched a webpage on the Health Professionals Portal to support doctors in better understanding appropriate claims under MOH’s prevailing guidelines. They are also collaborating with the Councils of the Singapore Medical Association and the Academy of Medicine, Singapore, to educate and reach out to both doctors and patients.

MOH’s focus is on providing affordable coverage for all Singaporeans and residents while ensuring necessary medical treatments are accessible.