ENHANCED GOVERNANCE TO GUIDE APPROPRIATE MEDISHIELD LIFE CLAIMS

The Ministry of Health (MOH) set up the Claims Management Office (CMO) in 2022 to guide and govern appropriate claim behaviours by strengthening governance over inappropriate MediShield Life claims, including over-servicing.

2.             The establishment of the CMO is part of various efforts to manage healthcare costs, alongside other measures, such as the development and publication of fee benchmarks to improve price transparency, use of evidence-based care practices to ensure their appropriateness, and regular surveillance audits to ensure compliance. These will moderate the escalation of healthcare costs, and help ensure the long-term sustainability of MediShield Life funds to protect Singaporeans against large bills for medically necessary treatments, whilst keeping premiums affordable.

3.             Prior to the setting up of the CMO, MOH was already conducting regular surveillance audits of MediShield Life claims. With the CMO, MOH now also conducts claims adjudication, which focuses on cases that complainants or whistleblowers surfaced, and outliers picked up by analytics. The adjudication of MediShield Life claims began in October 2022. Since then, 32 cases have been processed, of which 29 cases, involving 10 doctors, were assessed to be inappropriate claims, while the remaining three were appropriate. The common errors were the use of wrong surgical codes, over-servicing of patients, and submission of claims not covered by MediShield Life. Some examples of these inappropriate claims are in Annex A.

4.              The CMO also develops claims rules to provide clarity on appropriate claims. With the claims rules and adjudication process in place, the small minority of doctors who may be making inappropriate claims will have an opportunity to clarify and rectify their practices.

Claims Rules to Guide Appropriate MediShield Life Claims

5.             Claims rules provide clarity to medical practitioners on what an appropriate MediShield Life claim is[1], so that they can better advise their patients on what can be claimed from MediShield Life.

6.             Patients, too, benefit from the enhanced governance of MediShield Life claims. Patients undergoing a medically unnecessary procedure may be exposed to unnecessary risks, such as infection, injury, or adverse reactions to the medications prescribed. Financially, they may see their own or their family members’ MediSave savings being depleted unnecessarily and incur out-of-pocket costs. In the long run, the increase in MediShield Life payouts would also drive up the premiums that are paid by all Singaporeans and Permanent Residents.

7.             Specialty-specific claims rules have been developed by workgroups comprising public and private sector specialists in the relevant medical specialty, based on evidence-based literature, prevailing clinical practice, and cost-effective guidelines. These claims rules cover high-volume surgical procedures, or for those in which MOH has seen a certain degree of ambiguity or abuse e.g. cosmetic procedures claimed as medical treatment. Claims rules are finalised after consultation with the relevant specialist community, and are also verified against past MediShield Life claims to ensure that the majority of medically appropriate claims are covered.

8.             The first set of claims rules for gastrointestinal endoscopy was released in August 2022. Two more sets of claims rules were released in September 2023, for ear nose and throat, and cardiology.

Adjudication for Greater Scrutiny on MediShield Life Claims

9.             After MediShield Life claims have been processed, claims identified as highly likely to be inappropriate are further scrutinised. These claims are adjudicated by an independent panel appointed by the MediShield Life Council, comprising relevant public and private sector specialists. The claims adjudication process ensures panel decisions are objective by de-identifying panel members, and removing the identities of the patient, doctor and institution of the adjudicated case. The panel will assess the claim for compliance with various rules published by MOH [2]. If the claim is found to be inappropriate, the medical institution and/or doctor will be asked to rectify and refund the inappropriate portions of the claim and not recover the monies from the patient. The doctor may appeal within 30 working days with new evidence.

10.          MOH is stepping up our monitoring of inappropriate 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. In addition, such offenders may also be referred, where relevant, to the Commercial Affairs Department (under the Singapore Police Force) for investigation of potential fraud, or to the Singapore Medical Council (SMC) for breaches of the SMC Ethical Code and Ethical Guidelines.

Safeguarding Patients’ Interests from Medical Risks and Unnecessary Escalation of Costs

11.          Procedures which are not covered by MediShield Life, such as cosmetic surgeries, should not be claimed and patients would need to pay for these out-of-pocket. In the case of over-servicing, patients are exposed to unnecessary medical risks and may see their own or their family members’ MediSave savings being depleted unnecessarily and incur out-of-pocket costs. To help patients make more informed decisions about procedures, patients can consider asking the questions in Annex B during their discussions with their doctors. MOH’s website also provides patients with the estimated bill sizes and fee benchmarks to give patients an indication of the reasonable fee ranges for procedures.

Supporting Doctors in Submitting Appropriate Claims

12.          MOH has launched a webpage on our Health Professionals Portal to support doctors in better understanding appropriate claims under MOH’s prevailing guidelines. The webpage serves as a repository of resources for doctors to reference claims rules and case studies for educational purposes.

13.          MOH has engaged the Councils of the Singapore Medical Association and the Academy of Medicine, Singapore on the claims management initiatives and will work closely with them on further education and outreach to doctors and patients.

14.          MOH will continue to ensure that MediShield Life is able to cover medically necessary treatments in a sustainable manner, so that we can keep the premiums affordable for all Singaporeans and residents.

MINISTRY OF HEALTH

10 OCTOBER 2023

[1] In the form of clinical indication (i.e. whether a procedure is appropriate for a specific medical condition);

appropriate setting for a procedure (e.g. day surgery or inpatient admission); allowable frequency of claims; appropriate surgical coding for the procedure; and appropriate modality of treatment for specific procedures (e.g. instances where “technology-assisted” surgical treatments are claimable).

[2] These include the Table of Surgical Procedures (TOSP) Guidance, which is an exhaustive listing of surgical procedures that are claimable under MediShield Life or MediSave; the MOH Agency for Care Effectiveness’ (ACE) guidance; and claims rules for the relevant specialties. Deviations from these rules are allowed only if the doctor is able to medically justify his professional decisions.