The Philippine Health Insurance Corp. (Philhealth) issued an official statement regarding the temporary suspension of payment of claims, which has affected several health care facilities, doctors and other medical workers nationwide.
In a statement sent to The Bohol Tribune on Aug. 23, 2021 and attributed to Dr. Shirley Domingo, Vice President for Corporate Affairs/Official Spokesperson of Philhealth, she said that the state health insurance provider issued PhilHealth Circular No. 2021-0013, which suspends the payment of claims of health care providers (HCP) that are subject to investigations pertaining to fraudulent, unethical acts, and/or abuse of authority.
The Philhealth official clarified that this policy has been in place since 2016 based on the PhilHealth Circular 2016-026.
With this new Circular, the introduced additional provisions that would ensure that due process is observed before any temporary suspension of payment of claims (TSPC) is finally issued so as to allay fears of alleged arbitrary investigations among Philhealth’s HCPs, Domingo added.
The Circular was issued in the spirit of proper fund management and fraud control.
Fraud control is a basic tenet in managing funds. Hence, PhilHealth finds it imperative to implement measures to ascertain the security and sustainability of funds entrusted to it, she explained.
All HCPs can be rest assured that this policy will be enforced with respect to due process and existing rules and regulations, she quipped.
Likewise, this policy will affect only HCPs engaged in fraudulent acts against the funds entrusted to the Philhealthby its members.
PhilHealth assures its members and accredited HCPs that all good claims shall not be affected by this policy.
THE CIRCULAR
The Circular was signed by Philhealth’s chief executive officer Dante Gierran.
He said thatconsistent with the implementing Rules and Regulations of the Republic Act (RA) No. 7875, as amended by RA No. 9741, RA No. 10606 (2013 National Health Insurance Act) and RA 11223 (Universal Health Caro Act), Philhealth shall strengthen the mechanism to monitor the performance of HCPs, assess the outcomes of the services that they rendered.
The Philhealth is mandated to provide feedback to the HCPs as well as the public, he added.
“As steward of the National Health Insurance Fund (NHIF), PhilHealth employs measures in order to assure rational use of funds by detecting potential fraud or reimbursement abuse through dubious claims. In this light, and consistent with Presidential Decree No. 1445 it is imperative to institute policies and procedures that shall prevent continual loss of wastage of public funds due to indiscriminate or irregular use of the NHIF by imposing the TSPC against accredited HCPs at the onset of investigation under specific parameters and conditions,” Gierran said in the Circular.
In addition, Commission on Audit (COA) Circular No. 2012-003 dated October 29, 2012 entitled “Updated Guidelines for the Prevention and Disallowance of Iregular, Unnecessary, Excessive, Extravagant and Unconscionable (IUEEL) Expenditures” emphasizes the policy that government funds and property shall be fully protected and conserved. The IUEEU expenditures or uses of such funds of property should be prevented, the Philhealth CEO explained.
Gierran said the TSPC is a payment preventive measure against HCPs that are subject of investigation based on credible and verifiable report by the Philhealth or other duly authorized government agencies, owing to apparent and probable presence of fraudulent act, unethical practices and/or abuse of authority.
He further clarified that fraudulent acts “refers to any act of misrepresentation or deception resulting in undue benefit or advantage on the part of the doer or any means that deviate from normal procedure 4, and is undertaken for personal gain, resulting thereafter to damage and prejudice which may be capable of pecuniary estimation.”
Moreover, the term unethical acts “refers to any action scheme or ploy against the NHIP, such as overbilling, upcasing, harboring ghost patients or recruitment practice, or any act contrary to the Code of Ethics of the responsible person’s profession of practice, or other similar, analogous acts that put or tend to put in disrepute the integrity and effective implementation of the NHIP.”
On the other hand, abuse of authority “refers to an act of a person performing a duty or function that goes beyond what is authorized by the Act and RÄ 7875 National Health Insurance Act of 1995), as amended, or their implementing rules and regulations (IRR), and is inimical to the public.”