SINGAPORE: Private health policyholders under the Integrated Shield Plan can file to resolve clinical claim disputes through a new process from Tuesday (Nov 9).
Called the Clinical Claims Resolution Process (CCRP), it will help facilitate the resolution of disputes like unfair rejections of medically justifiable claims by insurers, as well as over-charging and overservicing by doctors or medical institutions.
“While disputing parties can of course at any point in time, as in the case today, refer cases to regulators for further regulatory action, the CCRP was set up with the aim of providing an objective determination for the parties and to facilitate a more amicable resolution to any of these disputes,” said Senior Minister of State for Health Koh Poh Koon at a briefing on Monday.
This is why the process will be voluntary, he added.
The new claims resolution process will be administered by a secretariat from the Academy of Medicine Singapore, and will be the main resolution channel for disputes of clinical nature under the Integrated Shield Plan, said the Ministry of Health (MOH) in a press release.
The process will also be supported by funding from the Health Ministry, said Dr Philomena Tong, medical director from the ministry’s MediShield Life claims management office.
Based on numbers for similar cases filed through the Financial Industry Disputes Resolution Centre, MOH also estimates that the process will see about 60 to 70 cases per year, though this may “pick up”, she added.
The cost of providing the new process is estimated to be about S$200,000 to S$400,000 per year, depending on the number of cases and the number of reviewers required each time, said Dr Tong, adding that these are “very rough” estimates.
What is an Integrated Shield Plan?
Integrated Shield Plans are made up of two components – MediShield Life, run by the Central Provident Fund Board, and an additional private insurance coverage component run by insurance companies.
The latter covers hospitalisation in A- and B1-type wards in public hospitals as well as private hospitals.
The insurers offering Integrated Shield Plans are: AIA, Aviva, AXA, Great Eastern Life, NTUC Income, Prudential and Raffles Health Insurance.
HOW THE PROCESS WORKS
For each dispute, a panel of five members will be convened, comprising specialists from the Academy from the relevant specialty and medical directors from selected insurers with the Integrated Shield Plan, said the Health Ministry.
The Consumers Association of Singapore (CASE) will also support the panel as a “consumer advocate”, the press release read.
As the process is voluntary, all parties must “mutually agree” to participate and enter into a contractual agreement to abide by the panel’s decision, said the Health Ministry.
However, parties should first attempt to resolve the disputes among themselves, before bringing it to the panel, the press release read.
The disputes should also be filed under the process within six months after the insurer’s final reply to the parties involved, said MOH in the release.
For example, policyholders with disputes about the insurers’ decision to turn down their claim should show that they have not been able to resolve the dispute with the insurer before filing one through the new process.
“This is because IP (Integrated Shield Plan) insurers have claims and dispute management capability that can deal with specific issues from an individual’s purchased IP,” the release read.
Cases brought to the panel will be anonymised to “ensure objectivity”, and those on the panel must be “free of any conflict of interest”, said MOH. Panel members will also remain anonymous to the parties involved in the dispute.
For disputes starting with insurers and medical practitioners or institutions, there will be a threshold of three incidents, said the Health Ministry.
In bringing an incident to the panel, the complainant must show that there were two or more prior related claims disputes with the other party within the last five years, indicating a pattern, the press release said.
This will ensure that one-off cases are not brought to the new process, said MOH in the release. However, this threshold will not apply to disputes that policyholders themselves bring to the panel.
Those filing a claim dispute through the new process can do so online at www.ccrp.com.sg. They will also need to pay an administrative fee per dispute - S$50, S$200 and S$500 for policyholders, medical practitioners, and medical institutions or insurers respectively.
Where there are subsequent cases involving “recalcitrant parties”, the complainant may be advised by the panel to refer the case to regulators including the Monetary Authority of Singapore (MAS), MOH or the Singapore Medical Council, depending on which parties are involved, said Dr Koh.
“MAS has informed MOH that they will take appropriate supervisory action against any insurer who has been determined by the CCRP panel to be at fault and recalcitrant,” he added.
EXPANDED PANEL OF DOCTORS
The number of private specialists on Integrated Shield Plan panels has also increased, said Dr Koh, adding that the committee has been working to increase the size of the panels to provide policyholders with a wider choice of specialists.
Currently, close to 80 per cent of 1,235 active private specialists are on at least one Integrated Shield Plan panel panel, said MOH in the press release.
This figure was about 20 per cent in 2019, Dr Koh noted.
Most Integrated Shield Plan insurers have “further committed” to gathering at least 500 private specialists for their panels by the end of this year, said the Health Ministry.
With this increase, about 80 to 90 per cent of private medical institution claims will be from providers on panels, the press release read.
“The MHIC has made very good progress in giving patients wider access to panel doctors and better choices to their appropriateness of care,” said Dr Koh.
With the launch of the new claims resolution process, patients, Integrated Shield Plan policy holders, doctors and insurers will have a platform for their issues to be deliberated on and resolved fairly, objectively and “hopefully much more amicably”, he added.
“With patients’ and policyholders’ interests at heart, MOH will continue to support the work of the MHIC and also this CCRP process to ensure that issues are heard and resolved between all the stakeholders.”