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Fees, referrals and insurance: staying clear of fraud

26 July 2018

Reports in Singapore warn that the Ministry of Health is looking closely at fraud and unethical practices across healthcare. Dr Ming-Keng Teoh, head of medical services (Asia) at Medical Protection, explains the pitfalls and consequences of dishonesty

With the Ministry of Health in Singapore looking at fraud involving unnecessary treatments and illegal referral fees, it is a good time to refresh your knowledge of the rules surrounding unethical practices in medicine.

Personal profit and/or incentives, financial or otherwise, should never affect your professional judgment. This includes referring patients and prescribing specific products.

The SMC, in its Ethical Code and Ethical Guidelines (section H1), states that you must only charge fees for services rendered directly by yourself or those directly under your supervision. You must not charge fees at a level that would bring the profession into disrepute.

Consultation fees

The fees or range of fees you set must be transparent and made known to patients in advance of providing services. However, patients’ acquiescence to your fees does not absolve you of the responsibility of charging reasonable fees.

You may collect fees on behalf of other doctors who have assisted you in your overall care of your patients, but you must not take additional fees for yourself if you have not materially provided any part of the services of the other doctors. If you have materially assisted the other doctors in providing the services, then you may legitimately charge a fee commensurate with the level of your participation.

Improper referrals

You should not receive any financial benefits or other incentives solely for referring patients or prescribing certain products. This means that while you may refer a patient to any hospital, nursing home, health centre or similar organisation if it is in the best interest of the patient, referrals based on any inducement from an organisation should be avoided. Any financial interest in an institution must also be disclosed to the patient before making the referral.

Pharmaceutical industry

You must handle relationships with companies in the medical industry with care. These companies include pharmaceutical, medical equipment or device companies, which often sponsor doctors on educational events or for research projects. You must be careful not to allow your relationship with these companies to influence or appear to influence your decisions on inter alia prescription of medicines and the choice of medical equipment, devices or procedures.

Gifts, hospitality or other inducements that may be provided by companies may affect or be seen to affect your judgment in making decisions about patient management. However, you may receive small, insubstantial gifts which will not be regarded as inducements by reasonable observers. Examples include stationery items or meals as part of educational events. Educational materials and items of medical utility, if of modest value, are also allowed if they improve patient care. There are some exceptions, such as donations or grants of money or equipment to hospitals, healthcare centres and universities, specifically for patient services, education or approved research. These must go through the prescribed channels.

It is improper to receive payments or benefits from pharmaceutical firms:

  • in relation to a research project, such as the clinical trial of drugs and appliances, unless the payments have been specified in a protocol for the project, which has been approved by the relevant local ethics committee (other than the ethics committee of the sponsoring pharmaceutical firm)
  • under arrangements for recording clinical assessments of a licensed medicinal product, whereby you are asked to report reactions observed in patients for whom you have prescribed the drug, unless the payments have been specified in a protocol for the project, which has been approved by the relevant ethics committee (other than the ethics committee of the sponsoring pharmaceutical firm)
  • if there could be influence over your professional assessment of the clinical value of drugs or appliances.

Insurance fraud

Stories have also emerged that some hospital workers are allegedly accessing patient records to see who has extensive medical coverage. What follows is the offer of upscaled medical packages and other services, allowing for the exploitation of the patient’s medical insurance. Section H3 of the Ethical Code and Ethical Guidelines warns against this and so-called ‘fee-splitting’ – in short, “you must not allow any financial constraints or pressures inherent in such schemes to influence the objectivity of your clinical judgment in managing patients such that you fail to provide the standard of care expected”.