Claims complaints process to be studied by panel for Integrated Shield sector

A CLAIMS complaints process may be in the pipeline for stakeholders in the Integrated Shield (IP) sector, to give patients and doctors "an avenue for recourse should they feel unfairly treated", Senior Minister of State for Health Koh Poh Koon announced on Monday.

Such a process is one of four "specific workstreams" that the 12-member Multilateral Healthcare Insurance Committee (MHIC) will tackle, he said in Parliament.

Fielding questions from Members of the House, he said insurers or patients "may wish to raise concerns about over-servicing or over-charging, and doctors may have concerns about certain insurer practices". These are examples of issues that may be brought up in a claim complaints process, to be supported by the Academy of Medicine Singapore (AMS) and the Life Insurance Association.

The three other tasks for MHIC are to:

* Look into insurers' medical panels and pre-authorisation;

* Improve transparency across the board, including making available more detailed and itemised information on healthcare bills; and

* Publishing data on claims and premiums.

The committee will also examine the issues from a patient and consumer-centric viewpoint to ensure that patient and public interests are "best safeguarded". In this respect, the Consumer Association of Singapore (Case) will lead a sub-committee to deal with this "comprehensively", said Dr Koh.

Unhappiness over insurers' pre-selected medical panels has intensified over the past few months, ever since it was reported that insurers would enforce a 5 per cent co-payment term for IP riders - even for policyholders who bought their full-cover riders before 2018. Policyholders may cap their co-payment share at S$3,000 a year, but they must use insurers' medical panels or seek pre-authorisation.

The issue has led to charges, among others, that insurers' medical panels are too limited, and that policyholders have little representation in the debate.

Dr Koh also said the Ministry of Health (MOH) will study whether IP insurance can be made "fully portable". This would enable policyholders to switch insurers and still have pre-existing conditions covered. "However, insurers may potentially need to increase premiums significantly for all policyholders to price in the increased risk they assume for portable IP that covers pre-existing conditions."

MediShield Life, he noted, covers all Singaporeans with no exclusions.

Over the past five years, an average of about 5 per cent of IP policyholders gave up their IPs each year. This may be because they opted for different coverage after considering the cost of premiums, their financial resources and healthcare needs, said Dr Koh. Their average age was 34.

Data on the number of policyholders who did not subsequently purchase a new IP or were later admitted to public hospitals is not available.

On the issue of medical ethics, he said the Singapore Medical Council's ethical code and guidelines stipulate that doctors should have the best interests of their patients at heart. This includes prescribing appropriate and cost-effective care that best meet their patients' needs.

"Access to medical care and clinical judgement should therefore not be influenced by empanelment nor any financial constraints or pressures inherent in any health system. Should doctors find that the conditions of being on a panel would impose constraints on their ability to care for patients, they may decide for medical ethical reasons not to participate in such panels."

He said patients can make claims for all treatments covered under their IP, regardless of whether a specialist is on the panel or not. MOH has encouraged insurers to grow the size of their panels, and to enhance their pre-authorisation processes, to give approval for treatments or hospitalisation beforehand. Pre-authorisation enables insurers to assess treatments for medical necessity and fee appropriateness, including for doctors not on their panel. "Some insurers have extended the co-payment cap to pre-authorised claims for treatment by non-panel doctors to provide policyholders with greater assurance, and we encourage more to do so."

He said some insurers have expanded their panels by more than 40 per cent since August 2019. Today, more than 70 per cent of private specialists are on at least one IP panel.

Dr Koh said some have asked whether the MOH's fee benchmarks can be used to determine insurance payouts. LIA has said between 5 and 15 per cent of IP claims were approved above the upper bound of the fee benchmarks. He said insurers need to take into account the medical complexity and specific clinical circumstances, and deviate from the benchmark "for justified and exceptional" cases.

Claims scrutiny, he said, may have been perceived as a challenge to a doctor's professional judgement. He said scrutiny of claims is important for the integrity of the healthcare system, and is a common practice internationally. "Insurers scrutinise claims to ascertain whether treatments were medically necessary and charged appropriately. This protects the interests of policyholders, who may otherwise see their premiums rise should claims be paid out indiscriminately."

Dr Koh said insurers should handle the process professionally and efficiently. "Insurers should not make the process onerous and ask for unnecessary information unrelated to the claims and impose a heavy administrative burden on the clinicians."

The information sought can be standardised and streamlined so it is not perceived as questioning the decisions and judgement of doctors. "If a particular claim is justified, insurers should pay according to the policy benefits. We will be looking into this issue."

On whether an IP insurer may decide to exit the market for commercial reasons or insolvency, he said the insurer or liquidator would seek to arrange for the IP policies to be transferred to another insurer to ensure continuity of coverage.