Integrated Shield coverage: Disputes platform set up, insurers' panel of doctors widened

INSURERS offering Integrated Shield Plans (IPs) have committed to expanding their doctor panels to as much as 500-600 private specialists by year-end, following a clash between doctors and insurers earlier this year over issues arising from changes to co-payment plans. A disputes platform known as the Clinical Claims Resolution Process (CCRP) for stakeholders in the IP sector to amicably resolve conflicts has also been established, the Ministry of Health announced on Tuesday (Nov 9).

The two main outcomes were arrived at after a 12-member Multilateral Healthcare Insurance Committee (MHIC) was set up in April to collaboratively address issues and provide innovative and balanced solutions that would safeguard patients' interests and ensure access to continuity of care.

Unhappiness over insurers' pre-selected medical panels first surfaced when it was announced that insurers would enforce a 5 per cent co-payment term for IP riders. 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 MHIC had been working to increase the size of insurer panels to provide policyholders with a wider pool of specialists on the panels.

The number of private specialists on IP panels have increased by up to 63 per cent since the beginning of the year. Close to 80 per cent of 1,235 active private specialists are currently on at least one IP panel, said MOH.

"Most IP insurers have further committed to ensuring that their panels reach a size of at least 500 private specialists by end-2021," MOH added.

With this, an estimated 80 to 90 per cent of private medical institution claims will be from panelled providers.

The number of specialists on each insurer's panel will depend on the size and composition of their own particular book of business, said Alan Ong, who represents the Life Insurance Association (LIA) on the MHIC.

An insurer with more children in its portfolio, for instance, may require more pediatricians, noted Ong who is also medical director at AIA Singapore.

Meanwhile, the CCRP will help to facilitate the resolution of clinically related IP claim disputes, including concerns on:

• Unfair rejection of claims for medically appropriate treatment or procedures
• Over-charging by medical practitioners and medical institutions
• Over-servicing by medical practitioners

The CCRP aims to provide "an objective determination for the parties" and "to facilitate a more amicable resolution to any of these disputes", said Senior Minister of State for Health Koh Poh Koon in a press conference.

Complainants will be able to file their disputes online via the CCRP website from Nov 9.

They will, however, be required to pay an administrative fee per dispute, subject to Goods and Services Tax. The fee is S$50 for IP policyholders, S$200 for medical practitioners and S$500 for medical institutions or IP Insurers. The CCRP will be supported by MOH funding and it expects to see about 60 to 70 cases a year.

The cost of the CCRP is estimated to be about S$200,000 to S$400,000 per year, though these are rough figures that will be dependent on the number of cases that come through, and the number of reviewers that required each time, according to Philomena Tong, medical director from the ministry's MediShield Life claims management office.

The CCRP is a voluntary process and parties must mutually agree to participate in the CCRP, and enter into a contractual agreement to abide by the panel's decision.

Parties should, however, first attempt to resolve the disputes among themselves before turning to the panel. The disputes filed with the CCRP should be within 6 months after the IP insurer's final reply to the medical practitioner, medical institution or policyholder.

To ensure that one-off cases are not brought into the CCRP, disputes originating from IP insurers, medical practitioners or medical institutions will have a "3 incidents trend threshold".

These complainants must show 2 or more prior related IP claims disputes with the other party within the last 5 years. This does not apply to policyholders and patients who can lodge a complaint even if an incident has only happened once.

For each dispute, the CCRP will convene a 5-member panel comprising Academy of Medicine, Singapore (AMS) specialists of the relevant specialty, as well as medical directors from selected IP insurers. The Consumers Association of Singapore will also support the panel as a consumer advocate.

To ensure objectivity, cases will be brought before the panel anonymously and panel members will also remain anonymous to disputing parties.

Once the panel comes to a decision, both parties will proceed to settle the case with each other.

For instance, if an insurer has brought a case against a doctor, and the doctor has been said to be overcharging, the doctor has to make good the overcharged amounts back to the insurer.

In a bid to guide and educate medical practitioners on the fair provision of service, the AMS has also established a counselling framework to support the CCRP process.

Doctors would be offered an option for counselling if the CCRP panel's determination is in favour of the IP Insurer or the policyholder.

Doctors who choose not to participate in the counselling process will have their reasons duly documented and and taken into account by the Singapore Medical Council in the event of a repeat offence.

In instances where there are subsequent cases involving recalcitrant parties, the CCRP panel will advise the complainant to lodge a complaint with respective regulators such as the Monetary Authority of Singapore, MOH or the Singapore Medical Council.

"The MHIC has made very good progress in giving patients wider access to panel doctors and better choices to their appropriateness of care. And with the launch of the CCRP process, patients, IP policyholders, doctors and insurers will have a platform for their issues to be deliberated and resolved fairly and objectively and hopefully much more amicably as well," said Koh.

These new initiatives were broadly welcomed by most stakeholders though some pointed out that there are still gaps to be addressed.

IP policyholder Pek Jia Wei said that she is relieved that there will be more options for her in the future.

"Previously when I was looking for my preferred clinic to seek treatments, many of my choices were not part of the panel which resulted in me delaying my treatment," she said.

While having more private specialists on IP panels is a positive outcome, Tan Chi Chiu, a gastroenterologist in private practice, said that the issue of a majority of panel doctors being contracted at the lower range of the MOH fee benchmarks has not been addressed.

He questioned why, if the benchmarks are deemed fair and reasonable, shouldn't every doctor who respects the fee benchmarks be invited onto the panels.

"In a nationwide system, such discrimination between two groups of otherwise equally qualified doctors is inappropriate and appears to favour insurers. The unfair negative implications made against non-panel doctors is also not addressed," he said.

Meanwhile, the CCRP is a step forward in ensuring that consumers' interests are protected, said the president of Consumer Association of Singapore (Case) Melvin Yong in a Facebook post.

"We hope that medical professionals and medical institutions will be more minded to charge fairly and only undertake medically appropriate treatments. This would help prevent potential excessive increase in insurance premiums and keep healthcare affordable for consumers," Yong wrote.

An executive senior manager at an insurance company who declined to be named said that the CCRP can help clients alleviate the "tedious and slow process of getting the claims through" when there are claim disputes.

When the insurer's claims officer cannot provide a satisfactory claim outcome, for instance, clients may end up having to appeal and go through another painful wait, he said.

Singapore O&G's chief executive Eric Choo said that while the CCRP may indeed help address some of the concerns relating to IPs, the process must be "efficient enough for the parties to opt for this dispute channel".

To add, it costs money to send a case to CCRP, Tan noted. This could be a huge disincentive for a man on the street or even a doctor. While IP insurers have to cough up more money to lodge a complaint, S$500 is no disincentive for a large company, Tan added.

The LIA said in a statement that it supports the establishment of the CCRP.

"The IP ecosystem is complex, and there are inevitable tensions between the interests of different parties. LIA Singapore has consistently called for all stakeholders to come together to resolve these issues. The MHIC has been a useful platform to surface, discuss and address the necessary trade-offs," said the association.

READ MORE:

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