Doctors suspended over inappropriate claims explain their actions

SINGAPORE - A general surgeon who was taken to task by the Ministry of Health (MOH) over inappropriate claims said the cancer-related surgical procedures she conducts are often complex, removing many organs during one operation.

Surgical oncologist Melissa Teo said the procedure to remove cancerous tumours in the abdominal cavity takes a long time, sometimes up to 18 hours, if it involves many organs.

Several cancers such as ovarian cancer and colorectal cancer tend to spread there, and Dr Teo said many such patients “have advanced cancers, and the complex operations are to help prolong their survival”.

When she made her claims while referring to the Table of Surgical Procedures (TOSP), she said she had felt the need to differentiate between surgical procedures that require the removal of only a few organs, and the ones that may necessitate the removal of many organs for clearance of cancer.

TOSP is an exhaustive list of procedures from MOH for which MediSave and MediShield Life can be claimed, and its codes focus on the intent and outcome of the surgical procedure, regardless of the surgical access route or technology used.

Dr Teo is one of two doctors who have been

suspended from making claims against MediSave or MediShield Life, including Integrated Shield Plans,

for six months, starting from Aug 5.

Dr Teo said: “I sought a meeting with and met MOH to clarify how to (meet the TOSP coding) to differentiate between complex (surgical procedures) taking up to between 16 and 18 hours to remove even up to eight organs, and some other simpler cancer surgical procedures.”

She told The Straits Times that she reached out to MOH in May 2023 and the latest meeting with the ministry was on June 9, 2023.

However, Professor Lucien Ooi, a senior surgical oncologist at Singapore General Hospital and National Cancer Centre Singapore, said that under TOSP, there is a single code that groups the removal of several organs, such as the stomach, pancreas and gall bladder.

Prof Ooi, who is chairman of one of the claims rule workgroups, cited another example: According to one TOSP code, for multiple operations such as a total hysterectomy, where the uterus, cervix, both ovaries and fallopian tubes are removed, only one claim can be made.

In its reply to media queries, MOH said it served two notices via e-mail and registered mail to Dr Teo.

The first was on July 1, to inform her of its intention to suspend her MediSave and MediShield Life accreditation for submitting six TOSP codes for procedures that would have been adequately covered by two codes.

The MOH spokesman said: “Dr Teo was informed that she could make representations by July 15 in response to the notice. We did not receive any representations from her by the stipulated deadline.

“(She was) served a second notice on July 29, informing her that her MediSave and MediShield Life accreditation would be suspended from Aug 5.”

MOH said the meeting Dr Teo requested with MOH representatives was held on June 9, 2023, in which she sought clarification regarding the use of a particular TOSP code.

At the meeting, the ministry added, it did not inform Dr Teo that using multiple TOSP codes in the way she had done was an acceptable practice.

The discussion was also not related to and preceded the inappropriate claims identified in MOH’s Claims Adjudication in relation to the July 2024 notices. 

The other doctor suspended from making claims for six months is ophthalmologist Natasha Lim.

MOH said Dr Lim submitted inappropriate claims for four cases involving two patients under TOSP codes for cataract surgery when the patients either had no cataract or had mild cataract that needed no surgery.

It also said that she claimed two surgical treatments for the prevention of corneal ectasia for two patients, which the expert panels of four or five senior doctors from the public and private sectors said is not standard care.

Corneal ectasia is a condition where the shape of the cornea changes.

Dr Lim said cataract surgery today is planned for even when a patient has better visual sharpness, pointing to recommendations under the principles of preferred practice in cataract surgery by the Asia-Pacific Association of Cataract and Refractive Surgeons.

The specific reasons for doing so include glare, when there is visual blurring in one eye, seeing double with both eyes open, and when difficulty in performing daily tasks is documented.

“With the high number of young people being heavily short-sighted, they tend to develop cataract early. They suffer reading difficulties and often do not like their vision, so we carry out cataract surgery early. We did not know what we were doing was frowned upon by MOH,” she said.

In the corneal ectasia cases, two of Dr Lim’s patients underwent refractive lens exchanges where their natural lenses were replaced with artificial ones to provide for better sight.

These are not claimable against insurance or MediSave.

Dr Lim said: “Patients with a high degree of myopia are often at high risk of ectasia. This is due to the thinning of the cornea, accompanied by increased myopia and astigmatism. The procedure was done to prevent the progression that will result in ectasia. We cannot wait till there is ectasia to do something about it because blindness cannot be reversed.”

Despite the “retrospective punishment”, Dr Lim said she will abide by the rule and wait out the six-month suspension.

“At the end of the day, I can understand where MOH is coming from. It is trying to ensure there is affordable healthcare for Singaporeans, especially when the population is ageing fast and MediSave is being used for the more serious conditions,” she said.