SMA Feedback on Medishield Life Claims Management

Dear SMA Members,

The Ministry of Health (MOH) Claims Management Office was set up in 2022 to develop Medishield Life (MSHL) claims rules and conduct claims adjudication.

MOH issued a press release on 10 October 2023 detailing the new initiatives to strengthen governance over MSHL claims. The press release and its annexes can be viewed at the following links:

1. Press release: https://bit.ly/492uKbh
2. Annex A: https://bit.ly/3M3HhS0

3. Annex B: https://bit.ly/48ZcYFN

We are glad to note that some of SMA's feedback to MOH have been taken on board following an earlier briefing on 3 October 2023, where MOH briefed SMA on the new initiatives and sought the SMA Council's feedback.

Please see below a summary of SMA's feedback and comments on the initiatives shared.

1. The SMA Council was briefed by MOH on 3 October 2023 regarding the new MSHL claims management initiatives.

2. We were briefed that:

   1. MOH would formalise a framework to guide and govern appropriate claims behaviours. These included claims rules to provide doctors greater clarity on what is appropriate to claim MSHL for, and claims adjudication to allow independent assessment for claims appropriateness by medical peers.
   2. MOH may initiate claims adjudication in cases suspected of overservicing, misuse of surgical codes to claim for higher fees and claims for cosmetic procedures that should not be claimed from MSHL.
   3. Enforcement would be tiered, and suspension of Medisave and MSHL accreditation would be for egregious cases (such as fraud) or for doctors with repeated or multiple non-compliances.

   4. Cases involving fraudulent claims may be prosecuted under Singapore law, and cases involving professional misconduct may be referred to the Singapore Medical Council.

3. We pointed out that the interpretation of surgical codes could be subjective, and that doctors usually submit surgical codes based on their interpretation of the codes and their assessment of the work that they did. For example,

   1. There may not be an existing surgical code for a new and approved procedure, so the doctor submits the closest equivalent surgical code.
   2. There may not be a surgical code for a bilateral procedure, hence the doctor submits two separate unilateral surgical codes.

   3. These would be isolated cases.

4. We made the following recommendations to MOH regarding the framework:

   1. The doctor who is unsure of the appropriate surgical code(s) should be given the opportunity to notify MOH to review his/her submission. In this situation, the doctor should not be considered as non-compliant.
   2. The framework should be targeted at the small minority of doctors who are suspected of egregious claims behaviour.
   3. The framework should allow for doctors who commit unintentional errors to be educated rather than have the error counted as one strike against them.
   4. The doctor who is suspended from Medisave and MSHL accreditation should be given the right to appeal against the suspension.
   5. The duration of suspension of Medisave and MSHL accreditation should be specified.

   6. The rectification process should be kept simple; eg, the format for submission could be the same as that of the Letter of Certification.

5. Last but not least, we opined that with the claims management process in place, insurers could be assured that the number of inappropriate claims would be reduced. This should give insurers the confidence to open up their panels and allow more specialists to join panels.
6. We are glad that MOH will be taking our feedback into consideration and will continue to work with the professional bodies, including SMA, to see how to review and streamline the processes further, including developing educational materials and sharing case examples with professionals and the public.
7. We will support MOH by circulating the relevant MOH announcements to our Members, and by featuring articles on appropriate claims behaviour in SMA News.
8. We understand that Members may be concerned about these measures, and we will continue to engage with MOH on this. We would appreciate it if Members would feedback their concerns to us.

Members can submit their feedback to the SMA Secretariat via email to szeyong@sma.org.sg.

Singapore Medical Association