Senator seeks audit of PhilHealth's case-based payment system

Akbayan Senator Risa Hontiveros is proposing several steps to protect the Philippine Health Insurance Corporation from fraud and other related scams.

Chief among Senator Hotiveros' proposals is the audit of PhilHealth’s current case-based payment system that reimburses healthcare providers with a predetermined, fixed rate for each treated case or disease.

Racked with "serious allegations, the case-based payment system has to be reviewed," she said in a statement on Friday.

"Allegations of fraud and financial mismanagement erode public trust in our healthcare institutions and endanger the lives of people by denying them the medical treatment they need. We need to have more stringent procedures to protect the public health sector against bad and abusive practices," she said.

"And if these procedures are already in place, they sorely need to be revisited and implemented. And those who have failed to implement these processes should also be held accountable,” Hontiveros added.

Reports have it that cases of over payment of pneumonia cases, cesarean section, and the Z package, among others.

State auditors had reportedly raised the issue during the years the system was being implemented.

Commission on Audit (COA) auditors suggested then that PhilHealth revisit the implementing guidelines of the policy, and to ensure that only valid expenditures be reimbursed.

Hontiveros expressed support for moves for PhilHealth to shift to a more strategic provider payment mechanism such as the Diagnosis Related Group (DRG). She said that she included the DRG as one of her amendments to the Universal Health Care (UHC) Law.

"The DRG is a system used to classify various diagnoses for in-patients into groups and subgroups so that insurance can accurately pay the hospital bill. The main idea behind this mechanism is to ensure that reimbursement adequately reflect the fundamental role which a hospital's case mix plays in determining its costs and the magnitude of resources that the hospital needs to treat its patients."

Likewise, the senator will also ask PhilHealth to produce and explain the current levels of support it provides its staff who report anomalies, and to regularly publish their current financial data on reimbursement claims for stronger transparency.

To deter and minimize fraud in the agency, Hontiveros will file the PhilHealth Insurance False Claims Bill, which is also hoped  to strengthen the corporation's anti-fraud detection systems. —LBG, GMA News