Health Ministry must do more to deter fraud

The news that several clinics are under investigation for possibly cheating the Ministry of Health (MOH) by making false or excessive claims for subsidies to patients, is extremely unsettling.

The MOH has already suspended two dental clinics for a series of "non-compliant" claims, including claiming for procedures that were not done. That was under the Community Health Assist Scheme(Chas) where the Government pays part of the cost of treatment for middle- and lower-income Singaporeans, and the Pioneer Generation(PG), at private dental and general practice (GP) clinics.

There have also been at least two cases of dentists making excessive claims from patients' Medisave accounts - without their express permission or even knowledge.

These show that even among doctors and dentists, professionals held in high esteem, there are crooks. That undermines the trust patients have in these medical professionals when some among them are willing to cheat to make a fast buck.

But doctors and dentists are not the only ones at fault. MOH also bears some blame.

The Chas and Medisave schemes have been described by one dentist as the equivalent of "a blank cheque". Speaking on grounds of anonymity, he and several other dentists said they reckon millions of dollars are being siphoned off by unscrupulous colleagues.

One gave the example of a procedure like scaling to remove plaque or prevent tooth decay, where it is left to the dentist to decide whether the work done was simple or complex. If the patient is a PG, the dentist can claim $30.50 for a simple procedure and $53 for a complex one. The dentist said: "For some treatments, I'd rather have a PG patient because the subsidy is more than what I'd charge my patients."

Take the example of a treatment that involves scaling, polishing and applying flouride to prevent decay, for which he would normally charge a patient about $75-$80. Under the PG subsidy, he can claim up to $114.

The MOH has even uncovered claims for procedures that were never done, or where patient case notes were so scanty it is impossible to ascertain the treatment given. The Straits Times understands that there are cases where copies of X-rays in a patient's file do not match the patient's teeth.

These could be due to sloppy practices but that too would be worrisome as poor note-taking and wrong X-rays can lead to wrong or inferior treatment.

In one case involving Medisave claims, the patient complained to the Singapore Dental Council that the dentist had misrepresented to her that the entire cost of a dental implant could be paid for by Medisave.

During the disciplinary inquiry into the case, it emerged that the dentist had made several claims against her Medisave - the $1,250 maximum for an implant and $950 for bone graft and $250 for drainage.

When the patient saw the $2,450 withdrawn from her Medisave, she asked the clinic for a breakdown of the claims, but did not receive any details. An X-ray by another dentist some months later showed that the patient did not have an implant.

The disciplinary committee said: "Misconduct involving the misrepresentation by a dentist, especially one involving using Medisave funds as an enticement, ought to be frowned upon."

In another case, the dentist was not found guilty because of the way the charges against him were framed, but the committee said if the charge had been a breach of professional ethics, it "would have been proved".

The dentist also could not produce a complete set of X-rays, which the committee said "was extremely shoddy".

It published its finding "for the benefit of the public and to raise the standard of the dental profession" without naming the dentist. The dentist had taken $3,700 from the patient's Medisave for various procedures. But the disciplinary committee found that he had not done those procedures. Instead, by making various claims from the complainant's Medisave Account, he sought to raise sufficient monies to pay for the dental implant procedure.

Dentists are apparently doing the same for Chas claims. These "Robin Hood" dentists believe they are helping poor patients who might otherwise find the treatment in question too expensive. They may have good intentions but making false claims to help patients enjoy bigger subsidies is wrong, and illegal.

In both Medisave cases, the patients noticed and questioned the amount of money withdrawn from their accounts. But that is because Medisave belongs to the individual. Subsidy from Chas comes from the Government, and while patients sign a consent form, few know the details.

While the MOH says it audits the clinics, such audits must necessarily be infrequent as the ministry's resources are limited. It is also difficult to know if procedures were actually done, without checking with patients. But medical and dental fraud can be a massive drain on public funds that would otherwise have gone to patient care.

Since 2007 the United States has recovered more than US$6 billion (S$8 billion) in fraudulent medical claims.

While the $167 million the MOH paid out in subsidies to GP and dental clinics last year is nowhere near that sum, and is just a small fraction of the ministry's annual expenditure of more than $9 billion, it should nevertheless take steps to prevent such abuse.

With improved technology, data analytics has helped insurers prevent such theft. For example, it can flag when a clinic regularly makes multiple claims for a patient against Chas or Medisave, which auditors can then follow up on.

Another way is to get patients themselves to help monitor claims. Most patients do not know how much Chas subsidy the dentist has claimed on their behalf; all they know is that they have to pay very little, or even nothing, for treatment.

But if they receive an itemised statement and see that claims have been made for procedures they did not have, they can alert the MOH to this.

Last year, 650,000 Singaporeans received Chas subsidy. If just a fraction of them scrutinise these annual statements and alert the authorities when there is a discrepancy, it will make policing the system much easier. Knowing that such a system exists would also give unscrupulous doctors and dentists pause.

It will not completely do away with fraudulent claims, but a foolproof audit would be too onerous. That could discourage people from using Chas, which would be a pity since it is a good scheme.

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A version of this article appeared in the print edition of The Straits Times on July 04, 2016, with the headline 'Health Ministry must do more to deter fraud'. Print Edition | Subscribe