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Introduction
The Claims Management Office (CMO) guides and governs appropriate MediShield Life claims
On this page
Objectives
The information and resources in this page are to guide doctors in making appropriate MediShield Life Claims. With better understanding, this will support doctors in their discussion with patients regarding treatment decisions.
Healthcare affordability is one of the key concerns of Singaporeans. Medical waste and abuse from inappropriate claims contribute to escalating costs, without benefiting patients.
Examples of inappropriate claims for MediShield Life and MediSave include:
Overservicing by doctor resulting in unnecessary treatments, procedures, or admissions
Overcharging through inappropriate usage of the Table of Surgical Procedure (TOSP)[1] codes to claim more for surgeries
Claiming for procedures that are not medically necessary, which should not be covered by MediShield Life and MediSave
Collectively, such behaviour expose patients to more risks of harm and also impact patients financially, as they lead to over-withdrawals from their MediSave or higher out-of-pocket payments. It also impacts all Singaporeans, as inappropriate claims are funded through policyholders' premiums.
The Claims Management Office (CMO)
In 2022, MOH set up the Claims Management Office (CMO) to help guide and govern appropriate claim behaviour.
CMO helps ensure that MediShield Life funds are used to pay for medically necessary treatments so that premiums remain affordable and the scheme remains sustainable.
The CMO helps manage claim behaviour by:
Progressively introducing specialty-specific Claims Rules
Medically scrutinising claims - Claims Adjudication
Through these, CMO also protects patients from unnecessary risks of harm and co-payment arising from inappropriate claims made by providers.
[1] The TOSP is an exhaustive list of procedures with table ranking, for which MediSave/ MediShield Life can be claimed. Any procedures not listed or without a table ranking are not claimable.