10 Doctors Face Consequences for Misusing MediShield Life Claims
In a recent development, the Ministry of Health (MOH) has taken strict enforcement actions against 10 doctors for making non-compliant MediShield Life claims. These claims included inappropriate treatments and the passing off of cosmetic procedures as medically necessary. The MOH's actions are part of the Escalation and Enforcement Framework (EEF) and aim to ensure proper claiming practices and adherence to clinical guidelines.
The affected doctors will undergo mandatory training on claiming practices and will be closely monitored for future claims. The MOH has also issued a stern warning, stating that further non-compliant claims could lead to severe consequences, including suspension or revocation of their MediSave and MediShield Life accreditation. The ministry did not disclose the names of the doctors involved.
These enforcement actions were a result of the claims adjudication processes handled by the MOH Claims Management Office. Specialist panels, appointed by the MOH and the MediShield Life Council, conducted the adjudication to ensure compliance with the rules. Since its establishment in 2022, the office has adjudicated 130 MediShield Life claims involving 44 doctors across 10 specialities, with enforcement actions taken against those who submitted non-compliant claims.
The office has also issued claims rules for four specialities, including gastrointestinal endoscopy, ear, nose, and throat, cardiology, and urology, to provide clearer guidance to healthcare professionals on appropriate claims under MediShield Life. These efforts have led to improvements in claims patterns, especially in the private sector.
One area of concern identified by the MOH is surgeons making claims against multiple table of surgical procedures (TOSP) codes for a single surgical operation, when such claims are unwarranted. These codes are unique identifiers used to classify surgical procedures for billing and insurance claims, ensuring accuracy and appropriateness. Among the 10 doctors facing enforcement actions is a general surgeon who submitted three claims with a total of nine TOSP codes for gastroscopy, colonoscopy, and haemorrhoid management for three patients. A specialist panel found that the doctor had inappropriately used codes from a higher-value procedure for four of these codes.
Another doctor, an ophthalmologist, had submitted a claim with one TOSP code for a corneal cross-linking procedure, which was later found to have no clinical evidence to justify the procedure. The MOH noted a 55% decrease in the number of claims with inappropriate TOSP codes between 2022 and 2024, and a general decline in the number of claims with multiple TOSP codes, leading to lower claim amounts and supporting the sustainability of insurance, including MediShield Life, for all Singaporeans.
The MOH also highlighted several claims involving the passing off of cosmetic procedures as medically necessary, thus eligible for MediShield Life coverage. Examples of such procedures include the correction of upper droopy eyelids, droopy eyebrows, and dermatochalasis (baggy eyes), which are not eligible for coverage under the national insurance scheme. Since 2018, guidelines have been in place to help ophthalmologists determine when such procedures are considered medically appropriate. However, in cases involving non-compliant claims, the ophthalmologist had signed off on assessments indicating visual blockage, which justified the need for upper droopy eyelid surgery. Upon review, the certified measurements did not match the clinical documentation, and the patient subsequently underwent surgery with a plastic surgeon, who submitted the MediShield Life claims.
The MOH emphasized that a claim for surgery not required to treat a medical condition was submitted. The ministry has issued a notification letter to the ophthalmologist involved, emphasizing the need to conduct proper certifications in adherence to the guidelines. The plastic surgeon, responsible for ensuring claim compliance, is now required to attend mandatory training under the EEF. The MOH reminded all ophthalmologists that inappropriate certifications resulting in non-compliant claims may be assessed for professional breaches and may be referred to the Singapore Medical Council if necessary. Principal surgeons who perform procedures and submit claims for MediShield Life are also responsible for ensuring compliance with MOH requirements and adhering to guidelines before submission.
