MOH’s Claims Office exposes 29 improper MediShield Life claims valued at S$400,000

SINGAPORE: An office specialized in addressing inappropriate claims under the MediShield Life program, a mandatory health insurance initiative in Singapore, has detected 29 cases involving 10 doctors since October 2022, as reported by the Ministry of Health (MOH) on Tuesday (10 Oct).

Collectively, these cases represent approximately S$400,000 in erroneous claims and involve a spectrum of misconduct.

This includes overcharges exceeding S$95,000, the provision of inappropriate treatments, and the misrepresentation of cosmetic surgery as legitimate medical procedures within the context of MediShield Life claims filed by doctors.

In 2022, the Ministry of Health (MOH) established the Claims Management Office (CMO) with the aim of providing guidance and oversight for proper claim practices, particularly in addressing inappropriate claims within the MediShield Life program, including cases of over-servicing.

Currently, the CMO is actively investigating an additional 70 cases, while intensifying its scrutiny of specific doctors.

Doctor charges excessive S$95,000 bill for cancer surgery

One example of inappropriate MediShield Life claims, as uncovered by the CMO, involves a case where a doctor submitted an inflated bill of approximately $95,000 for the surgical removal of a tumour from a patient with stomach and intestinal cancer.

Although the surgery was deemed medically necessary, the charges had been exaggerated through the use of multiple overlapping surgical codes, which was not only inappropriate but also potentially resulted in higher costs for the patient, leading to additional out-of-pocket expenses and unnecessary withdrawals from MediSave.

Another case involved more than S$5,600 in unwarranted claims, stemming from a doctor performing cross-linking surgery (a two-step procedure) on a patient with blurry vision and long-sightedness.

The panel investigating the case determined that the patient had cataracts and should have received cataract surgery instead of cross-linking surgery, putting the patient at undue medical risk.

Cosmetic surgery disguised as medical

In another case, a private-sector doctor submitted claims exceeding S$10,000 for the correction of ptosis, commonly known as “droopy eyelids.”

However, upon thorough review, the panel determined that the criteria for ptosis affecting visual function were not met, leading to the conclusion that the surgery was performed for cosmetic purposes.

The MOH statement noted that the correction for ptosis is eligible for MediSave or MediShield Life claims if the condition has resulted in the patient’s visual function being affected.

Unnecessary surgery uncovered

In a fourth case, a patient experiencing abdominal pain and a lower stomach mass underwent fibroid removal surgery.

Pre-surgical tests revealed non-cancerous fibroids and a uterine polyp, with ovarian ultrasounds indicating normal ovarian follicles.

Despite this, the doctor removed a small “ovarian cyst” found during the surgery, even though pre-surgery scans showed it to be a normal ovarian follicle.

The total charges from inappropriate items or codes amounted to more than S$9,900.

Penalties for repeat offenders of inappropriate claims

Doctors implicated in the 29 cases reviewed by the CMO office received warnings and education regarding permissible claims. However, formal enforcement measures were only put into place in April 2023.

For repeat offenders involved in inappropriate claims, MOH stressed that will take a progressive approach. The first offence results in a warning, followed by a warning coupled with mandatory training for the second offence.

The third offence will result in a six-month suspension of the right to submit MediShield Life claims on behalf of patients, with the doctor’s name publicly disclosed on the MOH website.

A fourth offence will lead to the revocation of the doctor’s right to submit claims, requiring reapplication for accreditation after a two-year period.

MOH: CMO office to monitor healthcare costs and govern appropriate claim behaviours

The MOH has underlined that the establishment of the new office is a pivotal component of their comprehensive strategy to control healthcare costs. This strategy encompasses the development of fee benchmarks and the implementation of regular surveillance audits.

“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.”

MOH explained that after the initial claims processing, those claims identified as likely to be inappropriate undergo adjudication by an impartial panel appointed by the MediShield Life Council. This panel employs an objective and de-identified approach to uphold fairness and transparency.

In cases of inappropriate claims, medical institutions and doctors are required to rectify and refund the inappropriate portions of the claim without recovering the funds from the patient. Doctors have the option to appeal within 30 working days with new evidence.

MOH said they are intensifying monitoring of inappropriate claims and are prepared to take action against doctors found to be repeatedly non-compliant.

MOH also warned that repeat offenders may face suspension or revocation of accreditation under MediShield Life and MediSave schemes.

“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.”

Caution urged on uncovered procedures and over-servicing

In the statement, MOH reiterated that procedures not covered by MediShield Life, such as cosmetic surgeries, should not be claimed, and advised that patients should be cautious of over-servicing, which can expose them to medical risks and unnecessary costs.

Additionally, MOH’s CMO office is also in the process of formulating claims rules to guide doctors in making appropriate claims.

The initial set, pertaining to gastrointestinal endoscopy, was released in August 2022, with two additional sets released in September 2023 for ear, nose, and throat procedures and cardiology. More sets of rules will follow.

Patients involved in cases of inappropriate claims will not be held financially responsible, as the responsibility to rectify the claims falls upon the doctors or medical institutions. These entities are prohibited from seeking reimbursement from the patients.