In private practice, I often find myself and my staff entangled in difficult situations and sometimes, our ethical tolerance may be tested. I wish to share some of these situations and perhaps we could all learn a thing or two.
Common compromising situations
Re-dating receipts
A patient once called my clinic staff asking for a change of date on the receipt, from the 28th of that month to the first day of the following month. He asked for the amendment as his company has a monthly limit for medical claims and he had exceeded the amount for that month.
My staff checked with me and I was shocked to hear such a request. According to the Inland Revenue Authority of Singapore (IRAS), receipts are legal tax documents and should not be amended once they have been issued. This is especially so as our company is GST-registered and cancelling a receipt without a valid reason may be viewed by IRAS as tax evasion.
Backdating referral letters
An old patient called me on the phone, asking me to write a referral letter for her to see another specialist. I thought the request was reasonable, but the problem is that she had already seen the specialist on her own. However, for her to claim the medical expenses from her company's insurer, she must have a referral letter.
To her disappointment, I declined her request as I did not feel comfortable backdating things.
Issuing multiple receipt copies
Some patients call to ask for reprints of receipts from their last visits, claiming that they had lost the originals. This is a legitimate request and we often oblige.
However, when I discussed this issue with my accountant, I was advised to put a stamp that says "DUPLICATE" on all reprints. This is because some patients may use the receipts to claim compensation from multiple sources, such as their personal insurance and company insurance companies.
It is safer and more proper for all reprints to be indicated as duplicates, as most insurance companies would demand original receipts for claim applications.
To my surprise, this new policy upset some patients, who insisted that we reprint original receipts upon their request.
Writing up multiple insurance forms
Many of my patients have their medical bills paid for by their insurance companies and it is quite common for them to ask their attending doctor to fill out some insurance reports.
To my surprise, some patients (mostly foreigners) asked me to fill out four to five different insurance forms for the same hospitalisation period. Initially, as usual, I obliged.
However, when I later spoke to some insurance specialists, I was surprised to find that multiple claiming for one hospitalisation is not practised in Singapore. When a patient has both personal and corporate insurance policies, he will not be able to claim compensation from both policies. He can claim from one policy first, and if there are deductibles or a cash outlay, he can claim the rest from a second insurance company.
Imagine this: if a patient who spends $1,000 in hospital bills could claim from five different insurance companies, he would end up having an extra $4,000 in cash.
Since then, I have only agreed to fill out forms from one insurance company for the same hospitalisation for free, and will impose a charge for subsequent forms. Besides that, I insist on putting the "DUPLICATE" chop on all reprinted receipts.
GST refunds
Under the Singapore law, foreign patients can claim a GST refund for unconsumed goods upon departure from Singapore and there are certain rules on the refund. By and large, most of my patients have no problem making the claims at the airport, but sometimes I encounter special requests. Once, a friend or relative of a foreign patient came to purchase medicine on behalf of a patient who was overseas, and requested for the receipt to be put in the name of the foreign patient.
From a medical standpoint, while I think it is the legitimate right of foreign patients to claim back the GST, I cannot prescribe medicine to their relative. I can only prescribe medicine to my patient and hence, the receipt can only show the name of the visiting patient.
Modifying an invoice
This is the most ridiculous request I have encountered. After I saw this patient at my clinic, I prescribed the medicine and issued a receipt upon payment. The patient proceeded to ask if my staff could mark up the amount on the receipt so he could claim more from his insurer.
Adding extra medicine
This request happened a few times. A patient and his spouse visited me for consultation and after making a diagnosis, I prescribed medicine for the patient. The patient's spouse then asked if I could double the amount of medicine as she, too, had similar complaints. So instead of a four-week supply, they asked me to prescribe eight weeks' worth of gastric medicine. Furthermore, they expected me to bill the patient's insurer altogether.
While I don't mind giving free consultations to a patient's relatives or friends, I do mind dispensing unreasonably large amounts of medicine. If his insurer asks me to explain why so much medicine is being given, I will have problems justifying my actions.
Prescribing an inpatient's drug to his caretakers
I had an inpatient with a digestive problem and I put him on gastric medicine. His caretaker had abdominal pain and requested for me to prescribe similar medicines for his use. I was prepared to waive my consultation fees, but I still needed to document history and physical findings, diagnoses, etc. I asked the caretaker to visit my clinic for a formal consultation and to pick up a prescription.
However, the caretaker just asked me to prescribe more inpatient gastric medication to the patient so he could consume the medication too. In other words, the cost of the caretaker's medication would have been added to the patient's bill. I felt very uncomfortable and rejected his demand.
Changing of medical reports
A few years ago, a young girl was admitted under my care for paracetamol overdose. At the emergency department, the resident physician did a gastric lavage and we gave intravenous N-acetylcysteine as an antidote. The patient recovered without sequelae.
A few weeks later, her mother called me to express her unhappiness that the hospital gave an itemised bill to her insurer, which included the cost of a gastric lavage. The insurer concluded that the patient must have had a drug overdose and declined the claim.
The mother asked if I could remove gastric lavage as a procedure from her hospital notes and hospital bill, but of course, I could not change history.
Extending medical certificates
I recently received a request from an old patient of mine who asked me to certify him unfit for his Individual Physical Proficiency Test. He was admitted seven months prior for cholangitis and choledocholithiasis, during which I performed an endoscopic retrograde cholangiopancreatography on him and my surgical colleague performed a laparoscopic cholecystectomy at the same admission.
I have always asked such patients to avoid doing strenuous exercises for at least six weeks after surgery, but stretching the "unfit for exercise" period to seven months is too extreme.
Why I don't comply
Personally, these requests are improper and some of them are ridiculous. Medical records and clinic receipts are legal documents and once printed, cannot be amended without valid reasons. Of course, if a mistake is made on my part, say in history or physical examination, I could make an amendment and date it accordingly. However, amending such legal documents without good and valid reasons, or in improper ways, is inviting trouble.
In addition, marking up the payment so that a patient can claim more from his insurer, or prescribing extra medication for their spouses or caretakers is, to me, fraudulent.
Why patients make such requests
Some patients are just trying their luck. They know that their requests are improper but they try anyway, as they have nothing to lose.
However, some patients are very pushy when their pockets are hurt. When their expectations are not met, they kick up a big fuss at my clinic reception. Many of these patients often say that other clinics accede to their requests and they are disappointed that we turn down their requests.
How to handle such situations
Firstly, use common sense. Most of these issues are very simple and commonsensical. Legal documents cannot be amended. Activities that happened cannot be deleted from records. Dates cannot be backdated. Medical leave durations have to be reasonable. Giving a patient additional medicine to treat his spouse, at the expense of his insurer, is plainly wrong.
Secondly, when in doubt, check with the experts. I often check with experts in various fields, like my clinic accountants, for queries on receipts and GST refunds, and my finance consultants about insurer issues. Their answers are usually very straightforward – a "yes" or a "no".
Thirdly, when still in doubt with no experts to turn to, turn to our peers. There is always wisdom in a group. Personally, I find the hospital doctor lounge, as well as SMA events, to be the perfect ground to seek opinion from our colleagues. I have learnt that whatever issues I face are also faced by other doctors and that I normally become wiser after discussing my problems with friends and colleagues.
In the end, I would explain to my patients why I cannot fulfil their improper wish, and try to convince them that they stand to lose more. For example, to the spouse of my patient who asked me to double my prescription so that he can get medications at the insured patient's account, I would tell him that if their insurer found out the truth, they would lose their whole policy. To the insurance agent who asked me to amend receipt dates so that it would be easier for his client to get claims, I would tell him that he risked losing his job if his company found out.
Why these problems exist
The problem comes mainly from the fear of displeasing our patients. During our training, we learn to take patients' complaints seriously and we often try hard to solve their complaints and problems. We are used to seeing our patients satisfied with our work, but we ought to separate medical problems from non-medical ones.
Actually, if we compromise, we may please the patient at that moment, but we put our practice and reputation at risk in the future, and it is just not worth it.
Final thoughts
I always tell my clinic staff (and myself) that we want to be known for practising good medicine, rather than being nice and compromising. If patients choose to leave us because we are too rigid, so be it.
At the end of the day, it is better to practise good medicine and good business ethics for a good night's sleep, than to please the patients and be worried later.