Forum: Insurance agents asking doctors to change codes to ensure claims go through
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I am a breast surgeon in private practice for six years. Even with my involvement in the Singapore Medical Association council and the Multilateral Healthcare Insurance Committee, I find myself bewildered and confused by the state of health insurance coverage, with its many terms and exclusions, and ever-changing rules.
Breast cancer is the most common cancer affecting women worldwide. The research into breast cancer care has developed tremendously and we can now provide personalised, targeted treatments in a multidisciplinary setting.
There is one situation now where surgeons are left helpless because while we want to provide the best care for patients, insurance coverage has not been consistent. This situation arises when a young patient with breast cancer is advised to go for gene testing, and a pathogenic gene mutation is found (the most well known being the BRCA gene).
The correct medical treatment for such a patient is for her to undergo bilateral breast removal, and sentinel lymph node biopsy as appropriate. This has been shown to reduce the chance of future breast cancer.
However, I have had several patients who have been told that this is classified as “preventive” treatment and is not covered by their insurance plan.
When applying for pre-authorisation, it behoves doctors to use the correct ICD 10, and TOSP codes, yet this gets rejected. I have patients whose agents tell them to tell me to use different codes to circumvent the problem to ensure that the claim will go through. In doing so, they are essentially telling the doctor to lie.
This needs to be discussed by all stakeholders – patients, doctors and payors – as we decide what is medically necessary, and will be paid for, and what is not.
International guidelines state that prophylactic mastectomy and oophorectomy is medically necessary surgery for patients with pathogenic mutations.
Now my questions are:
Is this procedure claimable under MediShield Life rules?
Should this be claimable under private insurance?
If insurance companies are not able or not willing to pay for this type of procedure, does it mean that all affected patients must have treatment in the restructured hospitals?
I look to the Life Insurance Association and the Ministry of Health to provide clarity.
Tan Yia Swam (Dr)
