Claims Management

INTRODUCTION

Purpose and Use 
The information and resources in this page are to guide doctors in making appropriate MediShield Life Claims. With better understanding, this will support doctors in their discussion with patients regarding treatment decisions.  

Healthcare affordability is one of the key concerns of Singaporeans. Medical waste and abuse from inappropriate claims contribute to escalating costs, without benefiting patients.  

Examples of inappropriate claims for MediShield Life and MediSave include: 

• Overservicing by doctor resulting in unnecessary treatments, procedures, or admissions
• Overcharging through inappropriate usage of the Table of Surgical Procedure (TOSP)^[1]  codes to claim more for surgeries
• Claiming for procedures that are not medically necessary, which should not be covered by MediShield Life and MediSave

Collectively, such behaviours expose patients to more risks of harm due to unnecessary treatments and also impact patients financially, as they lead to over-withdrawals from their MediSave or higher out-of-pocket payments. It also impacts all Singaporeans, as inappropriate claims are funded through policyholders' premiums. 


Role and Responsibilities of Claims Management Office (CMO)
In 2022, MOH set up Claims Management Office (CMO) to help govern appropriate claim behaviours. 

CMO's role is to help ensure that MediShield Life funds are used to pay for medically necessary treatments so that premiums remain affordable and the scheme remains sustainable. 

The CMO helps manage claim behaviours by:

• Progressively introducing specialty-specific Claims Rules
• Medically scrutinising claims - Claims Adjudication

Through these, CMO also protects patients from unnecessary risks of harm and co-payment arising from inappropriate claims made by providers. 

[1] The TOSP is an exhaustive list of procedures with table ranking, for which MediSave/ MediShield Life can be claimed. Any procedures not listed or without a table ranking are not claimable. 

CLAIMS RULES

What are Claims Rules? 
Claims Rules aim to guide the medical community on what constitutes an appropriate MediShield Life claim. They are not clinical practice guidelines per se but are derived from them.
 
Claims Rules make clear what is an appropriate procedure claim under MediShield Life in 5 key areas: 

• clinical indication
• setting of procedure
• frequency of claims allowed
• surgical coding
• modality of treatment for specific procedures

Claims Rules cover surgical procedures under a range of medical specialties. Claims Rules focus on procedures that have high utilisation, and/or a certain degree of ambiguity or potential for abuse. 

• Claims Rules are developed by MOH-appointed workgroups comprising public and private sector specialists, in consultation with representative specialist groups
• Claims Rules are based on published literature, prevailing clinical practice, cost-effective guidelines, and
• Claims Rules are verified against available past claims data to ensure that they cover the vast majority of claims that are medically appropriate
  

How are Claims Rules implemented?
MOH intends to roll out Claims Rules progressively every year and phased by specialties. Claims Rules will be refreshed every 2 to 3 years to ensure they keep in tandem with medical advances. 

• The Claims Rules for Gastrointestinal Endoscopy and Related Procedures were released in August 2022
• Cardiology and Ear, Nose and Throat (ENT) Claims Rules were released in September 2023
• Urology, Ophthalmology, General Surgery and Hepatobiliary, and Orthopaedics (Hip, Knee) Claims Rules are currently in the pipeline             
• Before each set of Claims Rules are enforced, a transition period (which is generally about six months) will be provided. During the transition period, doctors, and medical institutions whose cases are adjudicated, will be informed of the outcome for learning purposes 

Non-Compliance to Claims Rules

• Doctors with cases that are not in compliance with Claims Rules will be asked for their clinical rationale, should such cases be selected for medical adjudication by an independent Panel of experts appointed by the MediShield Life Council
• If a claim is adjudicated to be non-compliant with the Claims Rules, doctors and medical institutions will be asked to rectify the claim and the MediSave and MediShield Life monies improperly paid out under the claim should not be recovered from the patient
• Doctors with non-compliances to Claims Rules that cannot be medically justified will be monitored closely and enforced against. Refer to section on enforcement under claims adjudication

Please click here for infographic

CLAIMS ADJUDICATION

What is Claims Adjudication?

MOH started adjudicating MediShield Life claims against prevailing MOH guidelines and requirements in October 2022. Adjudication happens after the claim has been settled, thus preserving the current claim submission process.

• Claims Adjudication augments the current Table of Surgical Procedures (TOSP) surveillance audits conducted by MOHH's Group Internal Audit to encourage the provision of medically necessary treatments and prudent use of healthcare resources   

How are cases selected for Claims Adjudication?

Claims for adjudication are selected from two main sources:

• Cases that have been whistle-blown by patients, doctors, and insurers, and
• Cases where claims have been found to have deviated from peer norms, Claims Rules of that specialty and general financial claims rules and guidance issued by MOH e.g. Table of Surgical Procedures (codes for claiming fees for surgery), MediSave booklet, Agency for Care Effectiveness guidance 

What are the common types of Inappropriate Claims?

Common categories of inappropriate claims are as follows:

1. Inappropriate use of TOSP codes, such as
   • using proxy TOSP code(s) that do not accurately describe the procedure performed
   • submitting more than one TOSP code where a single TOSP code adequately describes the episode of surgery/procedure carried out (e.g. submitting multiple codes for doing Whipple’s procedure instead of the code describing Whipple)
   • performing each component procedure in a separate episode of surgery, for procedures that could otherwise be performed under a single TOSP code and/or episode of surgery/procedure
   • submitting TOSP codes for procedures which were not performed (This can constitute fraud, which can be prosecuted as a criminal offence)
2. Over-servicing, such as
   • unnecessary tests performed during an episode of admission
   • surgical treatment done before trial of conservative treatment (e.g. gastroscopy done on patient with 1^st episode of gastritis before trial of antacids)
   • unnecessary admissions for procedures that are commonly done in day surgery and attempt to claim health screening tests from insurance (usually not claimable)
3. Claims for procedures excluded by MediShield Life, including,
   • cosmetic procedures and health screening under disguise of diagnostic procedures/treatment. This can constitute fraud, which can be prosecuted as a criminal offence 

What is the process for Claims Adjudication?

• Cases are adjudicated by an independent Panel of 3-6 doctors appointed by the MediShield Life Council (MLC). The doctors are of the relevant specialty for the case in question, from both private and public sectors
• If a MediShield Life claim is selected for adjudication, the medical institution and doctor concerned will be notified in writing and be required to submit relevant clinical case notes and justifications to explain any deviation from MediShield Life claim requirements to the Panel 

Doctors would subsequently be informed of the outcome after the Panel has completed its assessment. The various types of outcomes are as follows:

1. If the Panel deems the claim to be appropriate for the patient, no change is required for the claim (i.e. MediShield Life and MediSave payout remains)
2. If the Panel deems the claim to be inappropriate, the medical practitioner and his / her patient may, within 30 working days of receiving the Panel’s assessment, submit new evidence to the Panel for reconsideration. However, if the Panel still concludes the claim to be inappropriate, the adjudication decision is final. The medical institution and the doctor will be asked to re-file the claim to rectify the inappropriate portion of the claim so that the MediShield Life and MediSave payouts could be adjusted and appropriately reflected. They should not shift inappropriate charges to other parts of the bill nor recover from patients

Please click here for infographic

Factors Considered in Determining Appropriateness of a Treatment Under a MediShield Life Claim*

In assessing the appropriateness of a treatment under the MediShield Life Claim, the Panel will consider the following, whether the claim is:

• Aligned to the Singapore Medical Council’s Ethical Code and Ethical Guidelines
• In accordance with current generally accepted standards of medical practice (peer reviewed journals, MOH Guidelines, ACE guidance, consensus statements, peer concurrence etc.)
• Clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for the insured person's illness, injury, or disease
• Not primarily for the convenience of the insured person, medical practitioners or medical in situations where treatment is able to be reasonably rendered in an outpatient setting
• Not of an investigational or research nature/unapproved by regulatory authorities
• Not preventive, screening or a health or aesthetic enhancement and
• Aligned with prevailing guidelines published by MOH and its appointed agencies, where relevant, including but not limited to MediShield Life Claims Rules, TOSP Booklet, Manual on MediSave/MediShield Life claims, Terms and Conditions for Approval under MediSave/MediShield Life schemes, MOH Finance Circulars related to MediShield Life/MediSave claims and ACE’s guidance, as far as such guidelines relate to the medical appropriateness of the treatment

*Above list is not exhaustive 

Case Studies

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Individual case studies of inappropriate claims/ adjudicated claims with outcomes. Cases are based on real cases, anonymised to protect patient confidentiality.