Introduction

Purpose and use

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 behaviours expose patients to more risks of harm due to unnecessary treatments 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.

Role and Responsibilities of Claims Management Office (CMO)

In 2022, MOH set up Claims Management Office (CMO) to help govern appropriate claim behaviours.

CMO's role is to help 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 behaviours 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.