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    Jul 03, 2014

    Overclaiming shadow over MediShield Life

    WHEN a cancer patient in her 30s met her doctor, one of his first questions was: How extensive is your medical coverage?

    And after finding out that she had an "as charged" plan, but without a rider to cover her co-payment - which could amount to a maximum of $20,000 - the doctor's next question was: Do you have $20,000?

    "It is the mentality of the doctor: see what plan you have, then decide on the treatment. That is worrying," said financial adviser Tiyo Chiat Haw, 36, who shared this story with My Paper.

    When MediShield Life kicks in next year, it will protect all Singaporeans, regardless of age and health condition, for life.

    The increase in premiums will be less than $360 a year, with most, if not all, absorbed by various government subsidies and top-ups in the first year.

    Yet, there is still the worry that high claims could place upward pressure on premiums.

    Claims have risen over the years. In July 2012, MOH revealed that the number of MediShield claims made per policyholder had increased by 9 per cent a year, while the average payout per policyholder had risen by about 12 per cent a year.

    Great Eastern said that its average claim cost per insured member under the integrated shield plans increased by 50 per cent between 2008 and 2011.

    So, could the possibility of overclaiming be a concern?

    Dr Khoo Kah Siang, president of the Life Insurance Association, said premiums cannot be managed effectively by insurers alone, and they are "stepping up efforts to work closely with health-care professionals, policymakers and relevant organisations to address these".

    Bills and fees have to become more transparent, he indicated. Benchmarks for such charges should be reviewed and unusually high bills scrutinised.

    Some financial consultants told My Paper that inflated claims tends to come from those covered under "as charged" integrated plans. Hence they believe MediShield Life, which covers B2 and C wards, will be unlikely to face a similar problem.

    But Jeremy Lim, partner at consulting firm Oliver Wyman, said there will always be a risk of overconsumption and overservicing, something that is inherent in the system regardless of type of coverage.

    That's because policyholders, insurers and health-care institutions sometimes have conflicting interests.

    "It is naive to ask hospitals to lower their revenue and expect them to do so wholeheartedly without balancing forces," said Dr Lim. "It is also naive to ask patients to be more responsible...when most rely on the advice of the doctors in deciding what treatment to opt for."

    To tackle this, he said some countries have specific claim limits for treatments or guidelines on appropriate treatments under which doctors who veer away from these guidelines do not get reimbursed.

    The United States practises value-based health care, in which hospitals are rewarded for quality and outcomes, instead of procedures.

    Kang Soon-Hock, head of the social science core at SIM University's School of Arts & Social Sciences, agreed that "overclaiming is an ever-present risk in any system" and said one way to prevent such practices is to constantly educate, not only the public, but also health-care providers on these dangers.

    "Furthermore, a stringent audit process to review all claims must be in place to ensure such malpractices are spotted and the necessary corrective actions taken," said Dr Kang.

    Health Minister Gan Kim Yong said on Saturday that the Ministry of Health will step up efforts to monitor claims, and that any unusual ones will be looked into.

    Tin Pei Ling, MP for Marine Parade GRC and member of the Government Parliamentary Committee for Health, said it is natural for people to be concerned, partly because the money belongs to everyone.

     But, Ms Tin pointed out, the co-insurance and the deductible should act as incentives for people not to overuse medical resources.

     These portions are not claimable and are to be paid either in cash or through Medisave.

    "What is equally important is that the co-insurance and deductible should not be so high that people with genuine medical problems are discouraged from seeking treatment," said Ms Tin.