In recent times, an insurance company has been auditing private specialists. Private specialists are queried retrospectively on justification for admission, indication for medications, billing, and the procedure codes that were used.
Some of the queried cases were admissions that took place more than two years ago.
After a few rounds of Q&A, the private specialists/hospitals were requested by the insurance company to refund previous payments that were made.
Doctors are slapped with a “fine” that can reach tens of thousands of ringgit. The main reason given was that the wrong procedure codes were used.
In Malaysia, private specialists tend to follow the Ministry of Health’s 13th Schedule or the Malaysian Medical Association’s (MMA) 5th Schedule for their procedure charges.
Certain procedures are not clearly mentioned, causing confusion and discrepancy in charges across the specialists.
Many private specialists reluctantly agree to pay back the insurance company instead of taking legal action because of two main concerns: long legal processes if this matter is escalated to the courts and fear of getting blacklisted by the insurance company, which can jeopardise the clinician’s income and the care of their existing patients under the insurance company.
A few questions come to mind.
Why did the insurance company not query the hospital bill at the time it was issued, usually at the time of patients’ discharge from the ward? Disagreements could have been resolved and payments could have been declined, if needed.
Is insurance clawback legal in Malaysia? If yes, what is the legal lookback period? It is certainly unfair to make a doctor pay back for a case seen years ago.
I hope MOH and Bank Negara Malaysia can protect our private specialists from getting bullied by insurance companies. There should be clear guidelines on this issue.
The author is a specialist who works in both the public and private sectors. CodeBlue is giving the author anonymity because civil servants are prohibited from writing to the press.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
