KUALA LUMPUR, Oct 15 — Private hospital operator IHH Healthcare Malaysia has objected to the exclusion of some of its consultant doctors from insurer AIA Malaysia’s panel on purported “commercial” grounds.
In a letter to AIA Bhd chief corporate solutions and health care officer Tung Hsiao Ley last Friday, IHH Healthcare Malaysia chief executive officer Dr Kamal Amzan raised concerns after AIA allegedly presented to doctors at Pantai Hospital Laguna Merbok (PHLM) in Sungai Petani, Kedah, that the exclusion of certain consultants from AIA’s panel was the outcome of negotiations with the private hospital group – which he denied.
“Our position has been consistent from the outset. We have repeatedly registered our disagreement and sought clinical, ethical, or professional justification for these exclusions. None has been provided to us,” wrote Dr Kamal in his October 9 letter to Tung, as sighted by CodeBlue.
“When AIA made clear that its decisions were purely commercial, we acknowledged its intention to proceed, without withdrawing our objections.
“I would appreciate AIA either correcting the impression conveyed to our consultants or refraining from representing IHH Malaysia’s position to them altogether. AIA is entitled to explain its own decisions, just as we are entitled to explain ours. Our discussions should not be presented as agreements we never made.”
Dr Kamal, who copied the affected consultants in his letter to AIA, said the concerns raised at PHLM extended across IHH’s network. IHH, one of the country’s largest private health care providers, operates 18 hospitals in Malaysia.
“Keeping hospitals on panel while excluding individual consultants creates unnecessary barriers to timely and continuous care, and complicates clinical operations,” he wrote.
The IHH Healthcare Malaysia CEO’s letter also indicated that the exclusion of some of the hospital group’s consultant doctors from AIA’s panel was made on a numerical basis.
“AIA’s proposal to reinstate one consultant at the expense of another is equally difficult to justify,” wrote Dr Kamal. “We cannot support an approach that merely transfers the exclusion from one doctor to another without addressing the underlying concern.”
He requested AIA to reconsider these exclusions across IHH Malaysia hospitals and reinstate all affected consultants, “unless there are clear, material, and substantiated grounds for their individual exclusion.”
It’s unclear how many IHH consultants, or across which specialties or hospitals, were either de-empaneled or not introduced to AIA’s panel. IHH declined comment when approached by CodeBlue.
AIA declined to answer CodeBlue’s questions, saying the matter related to specific provider network arrangements and ongoing discussions between the parties involved.
“As part of the management of our health care network, AIA regularly reviews panel arrangements to help ensure customers continue to have access to quality health care while supporting the long-term affordability and sustainability of medical coverage,” said AIA Malaysia in a brief statement to CodeBlue.
“AIA customers continue to have access to a broad network of hospitals and health care professionals across Malaysia. We remain committed to supporting the health care needs of our customers and their access to care.”
AIA Bhd, whose CEO is Heng Zee Wang, counts among Malaysia’s biggest insurance companies.
(Editor’s note: The writer of this article is an AIA customer holding a medical plan with an annual limit of under RM1.4 million).
AIA: Smart Panel Hospital Network Versus General Panel Hospital Network
According to AIA Malaysia’s website, the insurance company has two types of panel hospital networks: its preferred Smart panel and a general panel. A 20 per cent coinsurance/takaful on medical bills is charged if a customer visits an AIA general panel, AIA panel, or non-AIA panel.
In AIA’s panel health care provider listing, updated as of October 15 (today), the AIA Smart Panel Hospital Network is described as the insurer’s “curated network of hospitals throughout Malaysia based on the hospital’s commitment to deliver consistent and comprehensive health care to all AIA medical card holders”.
As for AIA’s General Panel Hospital Network, cashless facilities are limited to “specific departments and specialists within each hospital”. AIA medical card holders are strongly encouraged to refer to the AIA Panel Provider Specialist Listing to view the availability of cashless facilities offered to the “intended specialist or department prior to seeking treatment”.
AIA’s website doesn’t state that even within its Smart Panel Hospital Network, specialists can be further designated as either Smart or not.
A webpage on the AIA Smart Journey lists the benefits of seeking treatment from “Smart” specialists: “highly rated specialists” based on customer feedback on the AIA+ app, “reputable track record”, faster guarantee letter for hospital admission, and expedited claims approval.
However, although AIA’s Specialist Listing lists the names of various specialists across hospitals, the directory doesn’t state if a particular doctor is a Smart specialist, only their hospital category (Smart panel or general panel).
(Editor’s note: The writer of this article didn’t receive any letter from AIA about a list of Smart specialists, aside from notices on premium revisions for her 2021 policy every year from 2023 to 2027).
AIA Further Classifies ‘Smart’ Doctors In ‘Smart’ Panel Hospitals: Oncologist
A senior consultant oncologist, who practises at a large private hospital in the Klang Valley, said AIA started its Smart hospital and Smart doctor system last year.
He pointed out that with other insurers on the other hand, all doctors working in their panel hospitals are automatically covered, enabling consultants to refer cases to any one of their colleagues.
“But AIA took it a step further and has an additional level now, where you can be a Smart doctor in a Smart hospital or a not Smart doctor in a Smart hospital,” the oncologist told CodeBlue on condition of anonymity.
He expressed uncertainty about the criteria to be a Smart doctor on AIA’s panel, saying the “Smart” label had nothing to do with a doctor’s skill or seniority.
The oncologist claimed that a doctor who newly joins a panel hospital, regardless of seniority, must wait for about a year before they are made “Smart” by AIA, even if the hospital is a Smart provider.
“It’s like a probation period.”
The oncologist who spoke to CodeBlue is an AIA-designated Smart doctor, quipping: “I’m not proud of that.” He doesn’t know how he earned the designation because he didn’t receive any letter from AIA asking him to apply to be a Smart doctor.
He questioned how AIA assessed a doctor’s clinical acumen, if that was indeed the criterion for a Smart designation, such as if this was purely based on the bills sent to the insurance company.
“A very senior surgeon might do more complicated operations and their patients might stay longer, while simpler cases go to more junior surgeons,” said the oncologist.
He complained that AIA’s categorisation of panel specialists made things “significantly difficult” for doctors practising in a particular hospital because they were unsure which of their coworkers they could refer cases to.
“You might have a Prudential patient that you refer to a doctor and that doctor can treat, no problem. But for an AIA patient, you can’t refer to that same doctor.”
Some panel hospitals might not have two to three consultants for every subspecialty, but only one, and even that one person could just be a visiting consultant. Some neurosurgeons, he said, might only go to a few hospitals. “Then how?”
The oncologist explained that while technically, doctors can still refer AIA patients to a non-panel specialist, patients would likely have to pay first and claim later for a portion of the bill, such as procedure and consultation fees. He was unsure if pay-and-claim also applied to medicines prescribed by a non-Smart doctor.
Case Of Delayed Referral Because Doctor Wasn’t ‘Smart’
The oncologist related an incident where he saw a breathless female patient with metastatic breast cancer, whom he initially referred to a respiratory physician to perform pleurodesis, a procedure to prevent pleural effusions (extra fluid around your lungs).
“A few hours later, I got a call from the nurse saying that doctor isn’t a Smart doctor,” said the oncologist. “So I had to look for a respiratory physician who is a Smart doctor. Fortunately, there was another respiratory physician available at the same hospital at the time.”
That particular patient of his, however, still had to wait until the next day for the procedure because he needed to fill in a standard form for AIA to approve his proposed treatment plan.
“If it’s an emergency like a heart attack, bleeding, or a burst appendix, we have to treat it immediately, but if it’s a non-emergency, the patient has to wait. Pleural effusion can kinda wait for a few hours. Although the patient is breathless and on oxygen, it’s not like the patient will die immediately if you don’t do something now,” said the oncologist.
He complained that insurance companies sometimes asked “silly” questions, such as “what chemical do you want to inject into the pleural cavity?” or the planned delivery method of drugs.
Every specialist who sees an insurance or takaful patient must complete a form with their proposed treatment plan and get approval from the insurance and takaful operator (ITO) before treatment can start.
According to the oncologist, ITOs in Malaysia don’t employ oncologists on their internal medical panels to review and approve cancer treatment plans, except perhaps a medical doctor who isn’t a specialist. “I suppose they may use AI or Google to help them with the medical info.”
ITOs’ websites do not list the names or qualifications of their claim officers or members of internal medical panels tasked with reviewing claims or treatment plans. AIA Malaysia’s website, for example, doesn’t state if its subsidiary, AIA Health Services Sdn Bhd, has a medical director or who the person is if there is one.
Consultants Undergo Hospital C&P, ‘Smart’ Segregation Restricts Patient Choice
The oncologist pointed out that all doctors working in private hospitals already undergo rigorous credentialing and privileging (C&P), which is based on Ministry of Health (MOH) standards, before they practise.
AIA’s segregation of Smart versus non-Smart doctors, he said, can lead to delays in diagnosis and treatment, asking what would happen if a particular Smart specialist was on leave.
“Do you wait for that Smart doctor to come back from his leave?” he said. “It’s an additional headache for nurses, doctors, management, and patients.”
Ironically, a patient who is unwilling to pay for treatment by a senior non-Smart specialist might end up getting referred to a more junior and less experienced Smart doctor. “Smart or not Smart has no bearing on the expertise, skill, or seniority of the doctor.”
Besides delayed diagnosis and treatment, as well as potential complications with referrals, the consultant said AIA’s Smart doctor classification restricted patient choice. Some patients prefer doctors who speak in their native language, while others may prefer their regular specialist from clinic visits to also manage any inpatient care.
“Because of this, that doctor has to refer to another specialist that the patient may not know,” said the oncologist.
For patients with language barriers, especially elderly people, it might be difficult for doctors who don’t speak in the same language as their patients to explain their treatment plan or obtain consent.
The oncologist noted that AIA markets its insurance products with RM1 million or RM2 million annual limits to reassure customers not to worry about financial implications of treatment at a private hospital of their choice.
“Insurance is saying one thing when they want to sell their product, but in practice, they put limitations.”
