SQUIB GAME AND THE DYAD OF MEANNESS

squib – (noun) A short humorous or satiric writing or speech (Merriam-Webster’s Dictionary)

Since my last post, “Letters to Hobbit 2024” (https://hobbitsma.blog/2024/02/15/letters-to-hobbit-2024/), many more alert and mythical readers of this column have stepped forward to give me further examples of stupid questions and requests from high priests of the Insurer Order. While we politely call them high priests, I have been told these chaps have all the charisma, intelligence and persistence of a lice-infested orc.

Further examples of stupid questions:
• “Why do you follow-up the patient every six-monthly instead of 12-monthly” and “Why do you follow-up the patient 12-monthly instead of six-monthly (same insurance company)
• “Did you attempt conservative treatment for this patient before deciding on surgery?” (For a patient with anal fistula). Purported but unverifiable answer: No. Because like his insurer, he wants to be a perfect ass-hole.
• Why did you do a mammogram only on the left breast? (breast cancer found in the right breast and a right mastectomy had been done)
• Please give a memo describing the indications for and results of the colonoscopy done three years ago (for a claim on an operation for a fracture of the right ankle)

And the list goes on…..

This has become so big a problem that there are anecdotal reports that nurses now coming for job interviews with private specialist clinics not infrequently state up-front that their job scope must not include dealing with insurance companies and insurance claims; if not, they would rather not get the job. So private specialist clinics must now hire separate staff just to deal solely with insurance companies and claims.

Dealing with stupid questions invariably is very demoralising and mood-sapping. Other than perhaps an unreasonable patient or family member, there are few things that can ruin a healthcare worker’s mood more than a stupid question from an insurer. And since we are talking about better mental health and mental well-being for all, including healthcare workers, we should really help them by trying to minimise stupid questions. Stupid questions can be considered to be a kind of psychological abuse of the healthcare worker by certain inconsiderate members of the insurance industry. And since we do not even tolerate verbal or psychological abuse of healthcare workers from patients and their families nowadays, why should we tolerate abuse from these inconsiderate members of the insurance industry?

Time and resources spent answering (often repeatedly so) stupid questions could be better spent on more productive tasks like seeing more patients, not to mention the intangible costs of consequent low morale and poor mental well-being of affected healthcare workers.

All this leads to a less efficient healthcare system and higher healthcare costs because well, stupidity is expensive.

And so, in line with the constructive nature of this satirical column, this hobbit would like to propose that the relevant stakeholders of the health insurance industry start a forum or body to look into stupid questions posed by insurance companies and their staff to healthcare providers. We can call this the “Stupid Questions Under Investigation Bureau” (SQUIB). The administrative support of SQUIB will be funded by hopefully, MOH.

This is how SQUIB can work. The SQUIB Panel can consist of perhaps the following:

• A senior MOH doctor (maybe the Director-General of Health (DGH) or Deputy DGH to chair the SQUIB Panel. He will have the casting vote in the event of a tie
• A representative from Life Insurance Association (LIA) to represent the insurance industry’s interests
• A representative from either a Medical School (like a professor from YLLSOM) or a Professional Body like the Academy of Medicine Singapore to provide the doctor’s perspective on what is good practice of medicine
• A representative from the Consumers Association of Singapore (CASE) to represent patients’ interest

We can also hope that the SQUIB Panel will have a voting representative from the (somnolent) regulating authority for insurers. If this happens, this hobbit will buy 4-D, TOTO and Big Sweep all at one go.

SQUIB will process complaints from doctors about stupid questions from insurance companies. To discourage frivolous complaints from doctors against insurance companies, doctors will have to pay a non-refundable admin charge of say, $100 to SQUIB for each complaint filed.

SQUIB will then consider if the complaint is justified or not justified by its members voting. Whether a question is stupid or not will be decided by a majority decision by its members.

If the complaint is not-justified, nothing happens to the insurance company. If the complaint is justified, then the insurance company has to donate $1000 to a registered charity of the doctor’s choice, in the doctor’s name. If the registered charity is also an Institute of Public Character (IPC), then the doctor can claim a tax break from the donation.

There has been informal feedback that doctors are generally afraid to complain against insurance companies or use a forum like the Multilateral Healthcare Insurance Committee (MHIC) because they think they will be thrown out of the preferred provider panels of these insurance companies they had complained against. And it is indeed a fact that today, insurance companies can remove any doctor from their panel without giving any reasons – when it comes to whether a doctor can be on any panel, insurance companies are the judge, jury and executioner. Hence this climate of fear among panel doctors about bringing unfair insurance practices to light.

To allay these fears and promote transparency, the MHIC and SQUIB should require insurance companies to file a yearly list of doctors that have been removed from their panels and check if these doctors are also registered complainants to MHIC and SQUIB. Should they be, then MHIC and SQUIB can request a full report from the insurance company to justify why these doctors have been removed from their panels. If MHIC or SQUIB is not satisfied with the report, then they can refer the case to the insurance regulator for further investigation for possible victimisation of or retribution against complainants by insurance companies.

Finally SQUIB can publish a ranking of insurance companies according to the number of (proven) stupid questions complaints received by SQUIB. They should even publish the stupid questions themselves, if nothing but for a good laugh.

OK, so much for stupid questions. We move on to more latest developments in the health insurance sector. And yes, they are getting murkier by the minute.

Dyad Of Meanness

Recently, there has been feedback from a galaxy far, far away on quite a few incidents involving this insurance provider which we shall fictitiously call “I-come-steal”. Now, I-come-steal has not always been so coveting. They had been quite kind and cooperative previously and they had reimbursed doctors well, often up to the top end of benchmarks, giving doctors very decent income. But they have since left their cooperative stance and gone to the dark side.

Things got even darker when they appointed this claim administrator which happens to be owned by a major facility provider. We will likewise give this claim administrator a fictitious name, “I-am-strange”. There is obviously a potential conflict of interest with I-am-strange. I-am-strange can deny claims from doctors and then benefit from this denial at two levels. Firstly, they get the usual fees from the I-come-steal for services rendered. Secondly, they can shift the money they had squeezed from the doctor to the facility bill side, which will benefit their owners. Basically, they can swop or “exchange” the doctors bill to the hospital bill component. This hobbit has no evidence this has happened, but many doctors this hobbit has spoken to have brought up this potential for double benefit and potential conflict of interest. And apparently, bills incurred at other facilities do not incur the same kind of intense scrutiny as the ones incurred at facilities owned by I-am-strange’s shareholder, which only serves to reinforce this perspective on the ground. All this hobbit can say is I-come-steal and I-am-strange form a formidable Dyad Of Meanness, like The Emperor and Darth Vader.

Next, we move on to another purported example of this Dyad’s shenanigans. They are very quick to explore loopholes in our healthcare system. An example fee is the loophole found between Table of Surgical Procedures (TOSP) and fee benchmarks. In the interests of keeping up with progress in medical science, and to reflect current practice, there is a committee overseeing TOSPs that comes up with new TOSP procedure codes from time to time. So for example, a new surgical code may be created to reflect a combined operation involving two procedures. But the well-meaning TOSP committee’s creation of new codes is not link to the Fee Benchmarks Committee’s work. So this new code does not have an official MOH fee benchmark.

I-come-steal/I-am-strange then conveniently tells the surgeon that the use of an old code (for an operation he has performed for years) is now not accepted. He has to use the new code. The old code may have a fee benchmark (issued by MOH) that is from e.g. $10,000 to $20,000. As a result, the mid-point for the benchmark is $15,000, which is what the surgeon is claiming for, and also what he has been paid in the past. He is now told that he must claim under the new code, for which there is no MOH benchmark. Instead, I-come-steal/I-am-strange now issues their own benchmark of say, $11,000 to $15,000 for this new code. The midpoint is now only $13,000 and the doctor will be reimbursed as such. Which is kind of ridiculous when the new code is supposed to cover an operation which is more complex and involves more resource utilisation but which the insurer has conveniently given an internal reimbursement value that is lower than the old code (for a simpler operation), just because MOH hasn’t issued a fee benchmark for this. This surreptitious move to use new codes with no fee benchmarks is something policymakers should look out for. At the very least, perhaps a new TOSP code can be issued only if it comes with a fee benchmark, to prevent abuse by any insurance provider.

That’s all for this month. This hobbit really hopes someone in MOH will take up the proposal to organise SQUIB. SQUIB Game will be fun and charities will also benefit, which is a very good thing. In the meantime, let’s hope someone keeps a close watch on the unpleasant stuff being dished out there in spades by the Dyad.