PhilHealth urged to review, suspend circular on temporary suspension of claims payments

The House Committee on Health on Tuesday urged the Philippine Health Insurance Corporation (PhilHealth) to review and possibly suspend the circular on the temporary suspension of claims payments.

The panel approved Nueva Ecija Representative Estrellita Suansing's motion calling on PhilHealth to review and possibly suspend the circular without prejudice to any legislative remedy or measure that may be filed by the committee.

A dialogue between PhilHealth and hospital groups was held by the House Committee on Health to discuss the concerns regarding payment of claims and policies.

PhilHealth's Circular No. 2021-0013 proves the guidelines on the issuance of Temporary Suspension of Payment of Claims (TSPC) as a preventive measure against healthcare providers that are subject of investigation.

It states that suspending payment of claims that are subject of investigations pertaining to fraudulent, unethical acts, and/or abuse of authority has been in enforced by the state insurer since 2016.

Philippine Hospitals Association president Dr. Jaime Almora said several hospitals are alarmed by the PhilHealth circular.

He said PhilHealth has yet to settle billions of pesos in reimbursements, adding that hospitals are particularly wary that their COVID-related claims will be declared as "fraudulent" and the tag could unfairly taint the reputation of hospitals.

During the dialogue, Almora said hospital groups and other healthcare providers decided to review their engagement with the state insurer and continue negotiating with PhilHealth towards some goals such as the following:

• Avoiding biased and unfair evaluation of reimbursement claims by using qualified and knowledgeable claims evaluators. In the probe of alleged fraudulent claims, it is desirable that PhilHealth will commission qualified medical experts in active practice to investigate the claims;
• Refraining from oppressive or abusive use of quasi-judicial power. Due process is better served by submitting cases for arbitration to a "third party," which is impartial and unbiased;
• Exercising restraint on unfounded accusation of fraud and unethical practice because this will undermine and destroy the Trust and Confidence of patients towards their doctors and healthcare in general;
• Removing policies that create too much financial risk for hospitals so that they can proceed to improve and upgrade their hospital services without fear of suddenly losing their huge investment;
• Installing a representative of healthcare providers in the governing board;
• Increase in "Case Rate" as provided for in Section 10.4 of the Universal Healthcare law; and
• Immediately pay COVID reimbursement claims not later than the start of filing for renewal of accreditation of hospitals and doctors this October 1, 2021.

PhilHealth president Dante Gierran said they are willing to consider the recommendations of the hospital groups. —KBK, GMA News