29 inappropriate MediShield Life claims found as MOH steps up monitoring

The Ministry of Health (MOH) said that it has uncovered some 29 cases of inappropriate claims involving 10 doctors since last October. 

All the doctors were from the private sector, said the ministry on Tuesday (Oct 10), and the estimated amount that was inappropriately claimed is $400,000. 

These breaches were surfaced to the Claims Management Office (CMO) by whistleblowers or were picked up as outliers by the ministry's data analytics. The CMO, set up last October, then processes these cases to assess if the claims are appropriate.

Some of the common errors found were the use of wrong surgical codes for claims, over-servicing of patients, and submission of claims not covered by MediShield Life, said MOH. 

One of the cases was a doctor who submitted an inflated claim for surgery to remove a tumour from a patient with stomach and intestinal cancer. That doctor had used multiple surgical codes during the claims process.

The ministry said it is now looking at 70 more cases, and stepping up scrutiny of some doctors.

This adjudication process under CMO is part of MOH's efforts to strengthen governance over inappropriate MediShield Life claims to ensure the long-term sustainability of MediShield Life funds to protect Singaporeans against large bills for medically necessary treatments. 

This process focuses on cases where complainants or whistleblowers have surfaced, as well as outliers picked up by the ministry's analytics. 

It is conducted by an independent panel appointed by the MediShield Life Council, and is comprised of relevant public and private sector specialists. 

To ensure objective decision-making, panel members are  not identified, and the identities of doctors, patients and institutions are also removed. 

If the claim is found to be inappropriate, the doctor and the medical institution will be asked to rectify and refund the inappropriate portions of the claim and not recover the monies from the patient. 

MOH said that all providers were informed in October 2022 that different tiers of enforcement would take place for inappropriate claims filed after 1 April 2023. 

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Penalties can range from warnings to suspension of a provider's MediSave and MediShield Life accreditation. Cases that reflect potential misconduct and fraud will also be escalated to the Singapore Medical Council and police if needed. 

Patients whose MediShield Life claims have been adjudicated will be informed after the panel concludes its investigation. They will also be advised of any potential dispute channels for escalation, such as the clinical claims resolution process (CCRP) or the Consumers Association of Singapore (CASE).

Development of claims rules to guide medical practitioners 

Besides adjudication and enforcement, MOH has also rolled out claims rules to provide clarity on appropriate claims, and to allow doctors to clarify and rectify their practices. 

MOH said that it has currently has three sets of specialty-specific claims which have been developed by workgroups of private and public sector specialists — for gastrointestinal endoscopy, ear, nose and throat as well as cardiology. 

These claims rules cover high-volume surgical procedures, as well as those in which MOH has seen a certain degree of ambiguity. 

The health ministry shared that it intends to progressively expand the scope of claims rules to other disciplines. Current specialties that are not covered by claims rules will rely on existing measures that guide MediShield Claims.

READ ALSO: How to get the most out of your Integrated Shield Plan

claudiatan@asiaone.com