MOH takes enforcement action against six doctors over non-compliant MediShield claims

SINGAPORE: Two doctors had their MediSave and MediShield Life accreditation suspended on Monday (Aug 5), while another four will be required to undergo mandatory training after they were found to have made inappropriate MediShield Life claims. 
The Ministry of Health (MOH) named the two doctors who had their accreditations suspended.
They are Dr Teo Ching Ching Melissa, the sole director of The Surgical Oncology Clinic and Melissa Teo Surgery, and Dr Lim Pei Yee Natasha, the sole director of Natasha Lim Eye Centre. The other four were not named. 
MOH said in a news release on Monday that instances of their inappropriate claims were discovered through adjudication conducted by its claim management office (CMO), which was set up in 2022 to govern appropriate MediShield Life claims.
The cases are assessed by a panel of four to five specialists from private and public sectors, appointed by MOH and the MediShield Life council. 
Currently, Medisave and MediShield can be used to offset the cost of around 2,400 types of surgical procedures. These are listed in MOH’s Table of Surgical Procedures (TOSP), along with the claim limits for each procedure. 
The more complex the surgical procedure, the higher the claim limit on the surgeon’s fees. According to MOH guidelines, practitioners should only use one TOSP code if it adequately describes the procedure performed.   
However, in the cases of the six doctors, some had used multiple codes for a single surgery resulting in an inflated bill while some performed unnecessary treatments on patients. 
In the case of Dr Melissa Teo, a general surgeon, the panel found “severe” non-compliance in a MediShield Life claim she had submitted.
She had submitted the bill for six TOSP codes when two would have adequately covered the procedures that had been performed. This resulted in the inflation of her total claim, which amounted to S$170,000. 
This meant that the amount claimed for the other four TOSP codes – which was about S$90,000 – was inappropriate, said MOH. 
Dr Teo had previously been warned by MOH about similar non-compliances found in her claims in June last year. However, no enforcement action had been taken against her as this was before an enforcement framework came into force in April last year. 
Meanwhile, severe non-compliances were also found in six MediShield Life claims submitted by Dr Natasha Lim.
These include claiming for procedures for conditions that her patients did not have, and providing treatments that were not medically necessary for their conditions.
Dr Lim had submitted claims for cataract surgery but the ophthalmologist was later discovered to have performed refractive lens exchange instead, which is not claimable under MediSave or MediShield Life, and did not remove any cataracts.
She had also claimed for two surgical treatments of corneal ectasia (a group of conditions that affect the cornea) but the panel found that the patients did not have the condition.
Dr Lim later explained that the treatment was to prevent the condition, but this was not concluded to be standard of care by the panel. The total bills amounted to S$52,000, all of which were inappropriate. 
Against MOH’s instructions, Dr Lim had also attempted to recover the inappropriately claimed amounts from her patient for a claim that she was asked to rectify. 
With effect from Monday, both doctors and their clinics had their MediSave and MediShield Life accreditation suspended for a period of six months, which means patients who receive treatment from them during this period will not be able to pay for them using MediSave or MediShield Life. 
MOH said it has instructed both doctors to inform their patients of this prior to providing treatment.
“If their patients do require the use of (MediSave or MediShield Life), then the doctors should make appropriate arrangements perhaps even transferring care to other doctors or other settings where they may be able to use their claims,” said MOH. 
The other four doctors who were found to have non-compliant claims, which include unnecessarily performing treatments or admitting a patient into the hospital, as well as submitting multiple procedures than needed, are required to undergo mandatory in-person training.
They were referred to Dr C, D, E, and F in MOH’s news release.
Dr C, a gastroenterologist, had submitted a claim for gastroscopy and colonoscopy but the panel found that while the gastroscopy was appropriate due to the patient’s symptoms, the colonoscopy was not required as there were no symptoms referable to the lower gastrointestinal tract. 
While MOH acknowledged that it was not uncommon for doctors to perform a gastroscopy and colonoscopy in the same sitting, it added that there should be a reason for doing it.
“To do a procedure when it’s not necessary, becomes a concern,” said MOH. 
Dr D, a cardiologist, had submitted two claims for two patients who were unnecessarily admitted for an overnight hospital stay for a wide range of cardiac tests.
MOH said the patients, who were in their thirties, had been subjected to a “barrage” of tests including chest X-ray, blood tests, electrocardiogram, and exercise stress echocardiogram. 
The panel found that the patients were assessed to be at low risk for serious cardiac conditions and did not warrant inpatient admission as all of the investigations could have been performed safely in an outpatient setting. 
Dr E, an orthopaedic surgeon, had submitted two claims with a total of four TOSP codes each for two patients’ foot surgeries to treat bunions. In both claims, Dr E had submitted TOSP codes for more complex surgeries than what had been performed as well as used multiple codes when a single code was adequate. 
Dr F, an ophthalmologist, had submitted a claim for cataract surgery with a capsular tension ring (CTR) insertion. While the cataract surgery itself was necessary, MOH said the CTR insertion was not required in this patient’s particular case.
In addition to the mandatory training, these four will also be closely monitored for future claims and may have their accreditation suspended or revoked if repeated non-compliances are found. 
“We would basically re-educate them about the entire MediSave, MediShield life claim framework, the Table of Surgical Procedures framework, the coding rules, what constitutes appropriate and inappropriate behaviour,” said MOH.
“There may also be an assessment done to make sure that they fully understand the content of these sessions.”
The ministry added that it was in the process of finalising these details including the number of sessions and hours the training would require and what the assessment would entail.
Since October last year, the CMO has adjudicated a total of 34 cases of which 25 claims from 12 doctors were assessed to be non-compliant, said MOH.
Under the Escalation and Enforcement framework, errant doctors and dentists who make inappropriate claims can be subjected to various enforcement actions ranging from a warning letter for less serious cases to mandatory training, suspension and ultimately revocation of their MediSave and MediShield Life accreditation for the most egregious cases. 
The ministry said many cases were still ongoing but did not specify the number. 
MOH said it will progressively implement the same framework for non-compliances detected starting with MediSave and MediShield Life claims that are audited by MOH Holdings’ Group Internal Audit from Oct 1.
This will be extended to claims made under the Chronic Disease Management Programme (CDMP), Community Health Assist Scheme (CHAS) and other schemes from 2025. 
This is to align the various enforcement approaches across national financing schemes, said MOH. 
The six cases were part of a larger and separate review to uncover potential professional misconduct by doctors in their financial practices. 
“MOH takes a serious view against providers who make inappropriate or wrongful financial claims and will not hesitate to take strong action against the small minority of doctors who are found to be non-compliant, including referrals to the Singapore Medical Council for disciplinary action,” said the ministry. 
“This is part of MOH’s broader efforts to ensure that healthcare costs and premiums remain affordable for all Singaporeans.”
Editor’s note: This article has been amended to correct Dr Lim’s full name and to reflect that the inappropriate amount claimed was for four TOSP codes and not procedures. We apologise for the errors.