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No attempt to bring the TPAs under control
Published on: Sunday, July 16, 2017

By Dr Raj Kumar Maharajah
THE Medical Practitioners Coalition Association of Malaysia (MPCAM), which has more than 10,000 doctors as members, has been regularly receiving complaints about Managed Care Organisations (MCOs) and third party administrators (TPAs) from doctors through our online portal.

MCOs and TPAs are companies appointed by corporate bodies to manage the health benefits of their employees.

The most recent complaint is about a new trend by MCOs and TPAs to force doctors to pay anything between RM2,500 (as in the case of a well-known institution of higher learning) and RM5,000 upon being appointed as a panel clinic and RM250 annually (most recent case) in order to remain in the panel.

These new requirements by MCOs and TPAs are disturbing and unacceptable.

The MPCAM has on numerous occasions urged the Health Ministry to streamline and regulate MCOs and TPAs under the provisions of the Private Healthcare Facilities and Services Act 1998 (PHFSA).

In fact, since last year, we have been engaging the Medical Practice Division of the Health Ministry to firm up the draft copy of the regulation but to no avail.

We have about 30 TPAs currently managing the health benefits of employees, and all of them have their own set of fees and rules to be followed by doctors.

To be appointed as a panel clinic, some TPAs also require a “registration fee” which can range between RM100 and RM5,000. The doctor’s consultation fee as stated in the PHFSA is not followed but is conveniently sidelined.

TPAs determine the registration procedure of a client in a clinic. Each of the 30 TPAs sets its own procedures and requirements for registering a patient.

TPAs also have different procedures for submission of claims, and some even have a mandatory terminal attached to the clinic for which doctors are forced to pay a rental fee.

How many terminals are we supposed to have, and how many rentals do we have to pay?

Can you imagine 30 TPAs having 30 different terminals, and collecting rentals for this?

We have to pay registration fees upon being appointed as a panel clinic, monthly administration fees to be paid to the TPA, submission fees for each claim submitted, and payment fees when the payment is made to the doctor (sometimes up to six months later).

These irregularities have compromised healthcare of the public who visit private general practitioners in the following ways.

1. TPAs determine which hospital/clinic a consumer would be able to go to.

Hence, the consumer loses out on his choice of doctor or hospital/clinic. This is a fundamental right of the patient that is being compromised

2. All added fees mentioned above are paid by the doctor to the TPA. Our guess as to who will inevitably bear this cost is as good as anyone’s.

3. Each of the 30 TPAs has its own regulations concerning the fee to be paid by the employer and the fee to be paid by the doctor as “administration fees”. As we know, fee-splitting is illegal in the medical sector.

4. Some TPAs only allow a maximum medical fee for a patient for their daily visits.

Some even cap the number of medications which can be prescribed in a day.

5. By controlling the number of visits as well as limiting the charges and number of medications, justice cannot be served to the sick. TPAs should not involve themselves in the care and treatment offered by the doctor to the sick. This puts the doctor under tremendous pressure and constraints.

The Malaysian Medical Council (MMC) has not made a stand on the matter of whether it is unethical for doctors to be involved in a private independent contract with MCOs and TPAs, which involves fee-splitting at all levels, since the inception of this “middle man” idea in the 1990s. As such, MPCAM strongly urges the MMC to make a stand on this matter.

We are prepared to throw our agreements into the waste paper basket if it is indeed unethical!

Dr Raj Kumar Maharajah Medical Practitioners Coalition Association of Malaysia Putrajaya

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