[Doctors on a blacklist] Insurers may introduce a “non-recognised doctor list”. Who pays for medical insurance abuse claims?

For insurers, medical insurance is a double-edged sword. On the one hand, it is a huge source of revenue, involving substantial premium income. For Voluntary Health Insurance Scheme alone, the number of policies had exceeded 1 million by 2022 (Note 1). On the other hand, the large number of medical claims gives insurers significant claims costs. Bupa, which focuses on medical insurance, planned to introduce a “non-recognised doctors list” to ensure that “the healthcare service providers it works with all meet the company’s highest service standards”. However, the move drew widespread attention from the media and the medical sector, and Bupa eventually withdrew the list under external pressure, bringing the matter to an end.

Insurance companies are particularly concerned about the abuse of medical insurance claims, with the worst-hit areas being claims for skin tag removal and colonoscopy, which have led to substantial claims costs. Bupa stated that, on the grounds that “the healthcare service providers we work with all meet the company’s highest service standards”, it notified broker partners in November 2023 that it would soon launch an “Unrecognised Providers” list. Targeting policyholders of non-voluntary medical insurance, it said that from 1 January 2024 onwards, if insured persons use services provided by doctors on the list, the related expenses will not be reimbursed.

The contentious issue is the principles for compiling the “Unrecognised Providers” list. According to Bupa’s documents, “We will ensure doctors hold the appropriate licences and are registered, charge reasonable fees, and provide medically necessary treatment and services that meet customer needs.” “In very rare circumstances, a small number of healthcare service providers may not meet our standards, so we have placed them on the Unrecognised Providers list.”

Bupa has not provided an objective basis for determining what constitutes “necessary treatment and services” and “reasonable fees”, nor has it set an upper limit on the number of doctors on the list, which has drawn criticism.

It is understood that many insurance companies have long maintained internal “blacklists of doctors” for use internally, to alert claims teams to be cautious about individual claims cases, but this is the first time such a list has been made public in the market. 10Life was among the first to report on the matter after it came to light, and also sought further responses from the insurance company, the Hong Kong Federation of Insurers and doctors’ organisations. Subsequently, some media discovered a “list of non-approved doctors” on the Bupa Global website, involving four local doctors and one dermatology and aesthetic specialist centre, further fuelling the controversy. However, it should be noted that, in theory, Bupa Global and Bupa Hong Kong are two separate insurance companies, and this list should not affect Bupa Hong Kong policyholders. Accordingly, Bupa’s “list of non-approved doctors” had still not been made public at the time.  

On the other hand, the incident also drew the attention of doctors. The Medical Association issued a press release on its website, stating that it would seek legal advice and write to the Health Bureau. One of the nephrology specialists named on Bupa Global’s list, Dr Ho Kai-leung, also issued a statement, saying he was “deeply shocked and disappointed” by Bupa’s decision, and that he would reserve all legal rights in relation to the matter.

Under pressure from all sides, Bupa eventually backed down at remarkable speed. On 5 December, it announced that it would suspend issuing the “list of non-recognised doctors”, and that it would not publish any list on 1 January 2024. Bupa withdrew the list in less than two weeks.

As for the blacklisting of doctors and the issue of abuse in medical insurance claims, 10Life believes the incident is worth reflection by the insurance industry and the public alike:

• Insurers want to deter a small number of doctors from overcharging for medical fees by publishing a public blacklist, but is such a step really necessary? In fact, most medical insurance policies, including Voluntary Health Insurance Scheme (VHIS) policies, already contain two key clauses: “medically necessary” and “reasonable and customary charges”. The purpose of both is to prevent doctors from overcharging for medical treatment. Since policies already include these clauses, Bupa already has the right to decline some “unreasonable” or “unnecessary” medical expenses. Why would an insurer go to the trouble of creating a PR “incident” for itself? 
   
• The type of cover most severely affected by abusive claims is medical insurance, commonly known as “full reimbursement” insurance. Insurers’ marketing has long promoted policies with annual benefits of tens of millions of dollars, and some even claim a claims approval rate of 98.9%, easily giving customers the false impression that almost anything can be reimbursed. This has also led a small number of doctors to exploit the system. Insurers are also wary of enforcing the “medically necessary” and “reasonable and customary charges” clauses to control “unreasonable” claims. 
   
• Should insurers in fact change their marketing strategy and avoid using promotional phrases such as “full reimbursement”, “full coverage” and “all-inclusive”? If “claiming for everything” continues to occur, insurers will only respond by raising premiums aggressively, creating a vicious cycle in the end, with policyholders who play by the rules becoming the biggest losers.

Note 
1. Government News Release: Voluntary Health Insurance Scheme policy count exceeds one million (2 September 2022) 
Last updated: 15 December 2023. 

This English version of this article has been generated by machine translation powered by AI. It is provided solely for reference purposes. In the event of any discrepancy or inconsistency between this translation and the original Chinese version, the Chinese version shall prevail.