By:  Atty. Gregorio B. Austral, CPA

PhilHealth’s sanction on healthcare professionals with a clear lack of evidence violates due process  

This case involves the Philippine Health Insurance Corporation (PhilHealth) and Dr. Jose Mari Del Valle Galauran, a PhilHealth-accredited nephrologist. PhilHealth conducted an investigation of WellMed Dialysis and Laboratory Center Corporation (WellMed) due to allegations of anomalous claims. The investigation revealed that WellMed filed claims for dialysis sessions of a patient who had already passed away. Dr. Galauran, who was associated with WellMed, was accused of certifying these sessions and was subsequently charged with misrepresentation and breach of accreditation warranties. Dr. Galauran denied these allegations and argued that he was not involved in the fraudulent claims.

Despite his defense, PhilHealth withdrew Dr. Galauran’s accreditation.

Dr. Galauran appealed this decision, but his appeal was denied. He then filed a petition with the Court of Appeals (CA), which ruled in his favor, setting aside PhilHealth’s orders. The CA found that PhilHealth lacked the authority to revoke Dr. Galauran’s accreditation and that he was denied due process. PhilHealth filed a petition with the Supreme Court challenging the CA’s decision. 

The Supreme Court affirmed the Court of Appeals’ decision, ruling in favor of Dr. Galauran. The Court determined that PhilHealth acted arbitrarily and unlawfully in revoking Dr. Galauran’s accreditation and failed to afford him due process.

The Supreme Court’s ruling is based on the following key points:

  • Only the PhilHealth Board holds the authority to withdraw or revoke a healthcare provider’s accreditation.
  • The Court determined that a plain reading of the cited provisions of the law and the RIRR does not grant the PhilHealth President any quasi-judicial power of revocation or withdrawal of an accreditation.
  • The process for basic application for accreditation is separate and distinct from the withdrawal or revocation of accreditation.
  • While the PhilHealth President and CEO can resolve a basic application for accreditation, only the PhilHealth Board, exercising its quasi-judicial power, can act on the withdrawal or revocation of accreditation.
  • PhilHealth violated Dr. Galauran’s constitutional right to due process. The Court found that PhilHealth failed to furnish Dr. Galauran with a copy of the document that showed he allegedly received the amount of PHP6,650.00 for ghost dialysis sessions. This omission of a material document, which constituted a charge against Dr. Galauran, violated his right to due process. The Court also noted that PhilHealth’s own documentary evidence failed to substantially establish the violations alleged against Dr. Galauran.

The Supreme Court emphasized that it will not penalize healthcare providers when there is a clear lack of evidence to support a finding of administrative liability and will not deprive the public of their right to health and patient care services. (Philippine Health Insurance Corp. v. Galauran, G.R. No. 271209, (19 August 2024))