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Claims management
This outlines MOH's efforts to guide and govern appropriate MediShield Life claims to ensure funds are used for medically necessary treatments and the scheme remains sustainable.
Last updated 7 November 2024
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MOH is stepping up governance on MediShield Life claims to protect you from overservicing and overcharging by providers. Apart from incurring more out-of-pocket payments and increases in your premiums, undergoing surgery that is not medically needed may put you at risk of harm of injury and infection.
Read more on Enhanced Governance to Guide Appropriate Medishield Life Claims here.
MediShield Life Claims Rules
Claims Rules guide your doctor on what is appropriate for a MediShield Life claim in 5 key areas:
clinical indication (your medical condition).
setting (whether day surgery or inpatient admission).
frequency of claims allowed within a certain period.
surgical coding (the right code and combinations for claims).
modality of treatment (where ‘technology-assisted’ treatments are claimable).
Please click here for infographic [PDF, 1.1 MB]
MediShield Life Claims Rules will be rolled out progressively by specialties.
Title | Published Date | Last Updated | Case Study |
|---|---|---|---|
August 2022 | August 2022 | ||
September 2023 | February 2024 | ||
September 2023 | January 2024 |
Claims Adjudication
Assessment of post-hoc claims for clinical appropriateness.
After your MediShield Life claim has been processed, it may be picked up for scrutiny if it is found to deviate from Claims Rules and other MOH guidelines. Deviations are allowed if your doctor can provide medical justifications that are acceptable to an independent Panel of experts.
What is the process for Claims Adjudication?
However, if your claim was found to be non-compliant, your healthcare providers will be asked to rectify the claim and not recover the monies from you.
Please click here for infographic [PDF, 989 KB]
Common types of inappropriate claims found:
Inaccurate use of codes to inflate charges
Claims for procedures that were not performed
Disguising cosmetic procedures and health screening as treatment
Unnecessary tests and admissions (overservicing)
Providing surgical treatments before a trial of conservative treatment (according to clinical guidelines)
Treatments that are not appropriate for the medical condition
If your doctor is repeatedly non-compliant, they will be subject to enforcement action.
Here are some questions you may wish to discuss with your doctor before making the decision to undergo surgery.