Enforcement taken against 10 doctors for inappropriate MediShield Life claims

SINGAPORE - Between January and October, enforcement actions were taken against 10 doctors for making non-compliant MediShield Life claims for inappropriate treatments, as well as for passing off cosmetic procedures as medically necessary.

The 10 doctors will be required to undergo mandatory training on proper claiming practices and adherence to clinical guidelines under the Escalation and Enforcement Framework (EEF), said the Ministry of Health (MOH) in a press release on Nov 13.

“These doctors will also be closely monitored for future claims submissions, and may face more severe enforcement actions, including suspension or revocation of their MediSave and MediShield Life accreditation, if they are found to make further non-compliant claims,” MOH added. It did not name the 10 doctors.

These enforcement actions resulted from the claims adjudication processes of the MOH Claims Management Office. The adjudication was conducted by specialist panels, appointed by MOH and the MediShield Life Council.

The ministry noted that since its establishment in 2022, the MOH Claims Management Office has adjudicated 130 MediShield Life claims involving 44 doctors across 10 specialities, with enforcement actions taken against those who had submitted non-compliant claims.

The office has issued claims rules for four specialities – 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 yielded improvements in claims patterns, especially in the private sector,” MOH said.

The ministry identified surgeons making claims against multiple table of surgical procedures (TOSP) codes for a single surgical operation, when such claims are unwarranted, as an area of attention.

The codes are unique identifiers used here to classify surgical procedures for billing and insurance claims, to help ensure claims are submitted accurately and appropriately.

Among the 10 doctors facing enforcement actions is a general surgeon, who had 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, MOH said.

Another doctor, an ophthalmologist, had submitted a claim with one TOSP code for a corneal cross-linking procedure – used to treat a weakened or warped cornea – with the panel later finding no clinical evidence to justify the procedure.

MOH noted that the number of claims with inappropriate TOSP codes had decreased by 55 per cent between 2022 and 2024.

“We have also observed a general decline in the number of claims with multiple TOSP codes, which translates to lower claim amounts and supports the sustainability of insurance, including MediShield Life, for all Singaporeans,” it said.

MOH also noted that several claims involved passing off cosmetic procedures as medically necessary, and thus eligible for MediShield Life coverage.

The ministry cited correction of upper droopy eyelids, droopy eyebrows and dermatochalasis, or baggy eyes, as examples of procedures 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, the ministry said.

“In the above cases involving non-compliant claims, the ophthalmologist had signed off on the assessment that there was visual blockage, which indicated the need for upper droopy eyelid surgery,” MOH said.

However, when the cases were reviewed, the certified measurements did not correspond with documentation from clinical photographs, it added. It also noted that the patient involved subsequently underwent surgery with a plastic surgeon, who submitted the MediShield Life claims.

“In other words, a claim for surgery that was not required to treat a medical condition was submitted,” said MOH.

The ministry noted that a notification letter has since been issued to the ophthalmologist involved on the need to conduct proper certifications in adherence to the guidelines.

It added that the plastic surgeon, who was responsible for ensuring claim compliance, is now required to attend mandatory training under the EEF.

“MOH reminds all ophthalmologists that inappropriate certifications resulting in non-compliant claims may be assessed for professional breaches and may be further referred to the Singapore Medical Council if warranted,” the ministry said.

“At the same time, principal surgeons who perform procedures and submit claims for MediShield Life bear the responsibility to ensure that claims comply with MOH’s requirements and that all supporting documentation meets guidelines before submission,” it added.