New Clinical Claims Resolution Process established to resolve IP Claim Disputes

1.     From 9 November 2021, a Clinical Claims Resolution Process (CCRP) will be established to resolve claim disputes of a clinical nature between private Integrated Shield Plan (IP) policyholders, IP insurers, medical practitioners and medical institutions. IP insurers are also expanding their panels to include a wider pool of specialist doctors by end 2021.

2.     The Ministry of Health (MOH) had announced in April 2021 that the Multilateral Healthcare Insurance Committee (MHIC)[1] had been set up to collaboratively address issues related to health insurance. Amongst other issues, the MHIC was studying the establishment of a claims complaints process to provide a streamlined and integrated avenue to address disputes, and working to expand the size of IP insurer panels. The MHIC has made progress on both these fronts, and MOH has accepted the MHIC’s recommendations on these areas.

Scope of Clinical Claims Resolution Process
3.     The CCRP will help to facilitate the resolution of clinically related IP claim disputes, including concerns on unfair rejection of claims for medically appropriate treatment or procedures, concerns on over-charging by medical practitioners and medical institutions, and concerns on over-servicing by medical practitioners. The CCRP will be administered by a secretariat from the Academy of Medicine, Singapore (AMS), and will be the main resolution channel for IP disputes of a clinical nature, complementing the Financial Industry Disputes Resolution Centre (FIDReC).

4.     The CCRP is a voluntary process. The parties must mutually agree to participate in the CCRP, and enter into a contractual agreement to abide by the CCRP Panel’s decision. Parties should, however, attempt to resolve the disputes amongst themselves at the first instance. For example, policyholders with clinical-related disputes against the IP insurers’ decision to turn down their claim should show that they have not been able to resolve the dispute with the IP insurer before filing a dispute with the CCRP. This is because IP insurers have claims and dispute management capability that can deal with specific issues from an individual’s purchased IP. The disputes filed with the CCRP should be within six months after the IP insurer’s final reply to the medical practitioner, medical institution or policyholder.

5.     For disputes originating from IP insurers, medical practitioners or medical institutions, there will be a ‘three incidents trend threshold’. These complainants must show two or more prior related IP claims disputes with the other party within the last five years, which indicates a pattern of such disputes. This is to ensure that one-off cases are not brought into the CCRP. This threshold will not apply to clinical IP disputes that policyholders wish to bring to the CCRP involving their medical practitioners, the medical institutions or their IP insurers.

6.     For each dispute, the CCRP will convene a five-member panel comprising AMS specialists of the relevant specialty, as well as medical directors from selected IP insurers. The Consumers Association of Singapore will also support the panel as a consumer advocate. To ensure objectivity, cases brought before the CCRP will be anonymised before evaluation by the panel. Members on the panel must also be free of any conflict of interest pertaining to the dispute or the disputing parties. The panel members will also be anonymised to the disputing parties.

7.     Complainants will be required to pay an administrative fee per dispute, subject to Goods and Services Tax (GST). Please refer to Table 1 for the details.Table 1: Clinical Claims Resolution Process Fees Table

8.     Complainants will be able to file their disputes online via the CCRP website. Further information on the CCRP and the CCRP agreement form can be obtained from the CCRP website at www.ccrp.com.sg from 9 November 2021.

Insurers Panels Expanded by End 2021

9.     Medical panels and pre-authorisation are mechanisms that enable healthcare insurers to manage healthcare costs and premiums, while providing assurance to policyholders that their medical treatment and hospitalisation will be covered. They are commonly deployed by insurers around the world and, in recent years, also by IP insurers in Singapore.

10.     Today, IP insurers may provide additional benefits over and above the basic coverage for policyholders who visit doctors on their medical panels or have their claims pre-authorised. The MHIC has been working to increase the size of insurer panels to provide policyholders with a wider pool of specialists on the panels.

11.     Since the beginning of 2021, insurers have actively expanded their IP panels. The number of private specialists on IP panels have increased by up to 63%[3], and close to 80% of 1,235 active private specialists are currently on at least one IP panel. Most IP insurers have further committed to ensuring that their panels reach a size of at least 500 private specialists by end 2021[4]. With this, an estimated 80% to 90% of private medical institution claims will be from paneled providers. The full details of IP insurers’ panel expansion as of August 2021, and their committed panel sizes by the end of 2021 is in Annex B.

12.     The MHIC will continue to work collaboratively with all stakeholders to strike a balance between preserving patient choice for continuity of care, ensuring quality, cost-effective care and affordable premiums.

MINISTRY OF HEALTH

9 NOVEMBER 2021

[1] The MHIC comprises representatives from the Academy of Medicine, Singapore, Consumers Association of Singapore, Fee Benchmarks Advisory Committee, Life Insurance Association, Singapore, Singapore Medical Association and private hospitals. It is chaired by senior officials from the Ministry of Health and has in attendance a representative from the Monetary Authority of Singapore. The latest composition of the MHIC may be found in Annex A.

[2] The fees shown here are before GST.

[3] Great Eastern Life has expanded the number of private specialists on their IP panel by up to 63%. The rest of the insurers have expanded the number of private specialists on their IP panels between 7% (Raffles Health Insurance) to 49% (Prudential). See Annex B for further details.

[4] The last insurer, Raffles Health Insurance, has a small number of policyholders, and therefore committed to a smaller panel size of 250 private specialists.