MOH reveals enhanced governance to guide appropriate MediShield Life Claims

It will provide clarity to medical practitioners on claims to advise patients.

The Ministry of Health said there is an enhanced governance to guide patients and medical practitioners on what appropriate claims to get in MediShield Life.

“Claims rules provide clarity to medical practitioners on what an appropriate MediShield Life claim is so that they can better advise their patients on what can be claimed from MediShield Life,” said MOH, in a statement.

For patients, they can benefit from the enhanced governance of MediShield Life claims. For example, undergoing a medically unnecessary procedure may be exposed to unnecessary risks, such as infection, injury, or adverse reactions to the medications prescribed. 

Financially, they may encounter their own or their family members’ MediSave savings being depleted unnecessarily and incur out-of-pocket costs.

In the long run, a rise in MediShield Life payouts would also drive up the premiums that are paid by all Singaporeans and Permanent Residents.

A workgroup also developed speciality-specific claims rules based on evidence-based literature, prevailing clinical practice, and cost-effective guidelines. 

These claims rules cover high-volume surgical procedures, or for those in which MOH has seen a certain degree of ambiguity or abuse. For example, cosmetic procedures are claimed as medical treatment. 

“Claims rules are finalised after consultation with the relevant specialist community, and are also verified against past MediShield Life claims to ensure that the majority of medically appropriate claims are covered,” MOH added.

Adjudication for MediShield Life claims

After MediShield Life claims have been processed, claims identified as highly likely to be inappropriate are further scrutinised.

These claims are adjudicated by an independent panel appointed by the MediShield Life Council, comprising relevant public and private sector specialists. 

The claims adjudication process ensures panel decisions are objective by de-identifying panel members, and removing the identities of the patient, doctor and institution of the adjudicated case.