DELAYED payments and processing of claims by third-party administrators (TPAs) have left private clinics cash-strapped, said practitioners.

TPAs, also known as managed care organisations (MCOs), are middlemen enlisted by corporates to handle payments for their employees’ health bills.

A doctor who declined to be named said his outstanding claims with two TPAs amounted to RM24,000. However, the two companies have gone bust, leaving the claimant with no choice but to write off the claims.

Medical industry sources told The Malaysian Insight that late or unscheduled payments by TPAs are rampant.

Instead of paying clinics the lump sum for health bills within the stipulated period, some TPAs pay small amounts in stages.

“TPAs, or MCOs, have been deliberately delaying payments. For example, the health bill is RM1,200, and after other costs are included, the total payment due amounts to RM1,060. But they do not pay the lump sum,” said a source.

“Sometimes, you get RM120, and the next time, you get RM400. How do clinics survive and cover costs?

“On top of all of this, you also have to worry – what if these TPAs close up shop?”

Clinics must pay a fee of between RM2,500 and RM5,000 to be added to the list of panel clinics.

“There are instances where TPAs charge RM2 to RM5 per patient as the panel fee. They also set the consultation fee at between RM10 and RM15,” said the source.

Doctors are crying foul over the low consultation fee, which leaves them with little to make a profit once operating costs are factored in.

The source said diseases and their prescriptions are predetermined in the claims-processing system.

Clinics are also charged installation and monthly fees by TPAs for the claims system.

With that in place, said the source, doctors are restricted from giving their best to patients.

The source added that TPA personnel frequently conduct surprise visits to clinics, which could face suspension if they are found to be prescribing medicines that are not on the predetermined list.

“Sometimes, there are surcharges if there is a technical problem in the system. On top of that, if a clinic has branches, it can register only one branch.

“TPAs are nefarious. They profit from both clinics and client companies that enlist them for panel services.

“Clinics, on the other hand, are burdened by all sorts of charges just to be on the list of panel clinics.”

Some are stuck in limbo as they are bound by long-term contracts with TPAs.

Private clinics appear to face more pressure from government-linked TPAs, said sources.

The Malaysian Islamic Doctors Association said escalating operating costs are forcing doctors in private practice to close their clinics, with rental and the cost of buying medicines comprising the bulk of their expenses.

Some 500 private clinics have closed in the past few years, and more are expected to follow suit if no solution is found, it said. – May 27, 2019.