ENFORCEMENT ACTIONS TAKEN AGAINST TEN DOCTORS FOR NON-COMPLIANT MEDISHIELD LIFE CLAIMS

               As part of ongoing efforts in claims governance, the Ministry of Health (MOH) has taken enforcement actions against ten doctors between January and October 2025 for making non-compliant MediShield Life claims. Under the Escalation and Enforcement Framework (EEF), these doctors will be required to undergo mandatory training on proper claiming practices and adherence to clinical guidelines.

Impact of Strengthened Claims Governance

2.               These enforcement actions resulted from the claims adjudication processes of the MOH Claims Management Office (CMO). Since its establishment in 2022, the CMO has adjudicated 130 MediShield Life claims involving 44 doctors across 10 specialties, and enforcement actions were taken against practitioners who submitted non-compliant claims. In addition, the CMO has issued four sets of Claims Rules¹ to provide clearer guidance to healthcare professionals on appropriate claims under MediShield Life.

3.               These efforts have yielded improvements in claims patterns, especially in the private sector. An area that MOH pays attention to is when a surgeon claims against multiple Table of Surgical Procedure (TOSP) codes for a single surgery, when it is unwarranted. From 2022 to 2024, the number of claims with inappropriately paired TOSP codes, as defined by the Claims Rules, decreased by 55%. We have also observed a general decline in the number of claims with multiple TOSP codes, which translates to lower claim amount and supports the sustainability of insurance, including MediShield Life, for all Singaporeans.

Mandatory Training for Ten Doctors

4.               Since January 2025, adjudication completed by specialist panels, appointed by MOH and the MediShield Life Council, found ten doctors to have submitted non-compliant claims. These claims involved practices such as inappropriate multi-coding, upcoding, inappropriate treatment, and submitting cosmetic procedures as medical claims. Please refer to Annex A for details of these cases.

5.               All ten doctors will undergo mandatory training under the EEF to familiarise themselves with the prevailing MOH guidelines and proper coding practices. These doctors will also be closely monitored for future claims submissions, and may face more severe enforcement actions, including suspension or revocation of their MediSave and MediShield Life accreditation, if they are found to make further non-compliant claims.

6.               Of note, several claims adjudicated during this period involved practitioners passing off cosmetic procedures as medically necessary. Treatments that are not medically indicated are not eligible for MediShield Life coverage. Examples of such procedures include correction of upper droopy eyelids, droopy eyebrow and dermatochalasis for baggy eyes. MOH, in consultation with the College of Ophthalmologists, had previously developed a set of guidelines to guide the ophthalmologist community on how to conduct proper functional assessments for patients to determine when such procedures are considered medically appropriate. These guidelines have been in place since 2018.      

7.                In the above cases involving non-compliant claims, the ophthalmologist had signed off on the assessment that there was visual blockage, which indicated the need for upper droopy eyelid surgery. However, when the Panel reviewed the cases, it found that the certified measurements did not correspond with documentation from clinical photographs. These patients subsequently underwent surgery with a plastic surgeon who submitted the MediShield Life claims. In other words, a claim for surgery that was not required to treat a medical condition was submitted. MOH has since issued a notification letter to the ophthalmologist involved on the need to conduct proper certifications in adherence to the guidelines and has notified the plastic surgeon, who is responsible for ensuring claim compliance, to attend mandatory training under the EEF.

8.               MOH reminds all ophthalmologists that inappropriate certifications resulting in non-compliant claims may be assessed for professional breaches and may be further referred to the Singapore Medical Council if warranted. At the same time, principal surgeons who perform procedures and submit claims for MediShield Life bear the responsibility to ensure that claims comply with MOH’s requirements and that all supporting documentation meets guidelines before submission.

Continued Enforcement

9.               MOH takes a serious view against healthcare providers who make inappropriate or wrongful financial claims and will continue to take strong action against non-compliant practices. These enforcement actions are part of MOH's broader efforts to ensure that healthcare remains affordable for all Singaporeans, whilst maintaining quality care.

10.           Healthcare professionals are reminded to ensure all treatments, services and procedures are clinically appropriate and to familiarise themselves with prevailing MOH guidelines and circulars.

¹The four sets of Claims Rules are on Gastrointestinal Endoscopy, Ear, Nose and Throat, Cardiology and Urology. These can be found on Claims Management webpage.

Annex A

DOCTORS WHO ARE REQUIRED TO UNDERGO MANDATORY TRAINING