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PhilHealth to suspend payment of claims under probe

The Philippine Health Insurance Corp. (PhilHealth) on Friday said it will be suspending the payment of claims of hospitals and healthcare institutions or providers that are subject of investigations.

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

In a statement, the state insurer said suspending payment of claims that are subject of investigations pertaining to fraudulent, unethical acts, and/or abuse of authority has been in place since 2016, pursuant to PhilHealth Circular No. 2016-026.

“With this new Circular, the Corporation introduced additional provisions that would ensure that due process is observed before any TSPC is finally issued so as to allay fears of alleged arbitrary investigations among our providers,” it said.

“The Circular was issued in the spirit of proper fund management and fraud control,” it added.

“Fraud control is a basic tenet in managing funds.”

The issuance of the latest circular came amidst the issue of billions of pesos worth of unpaid benefits claims of PhilHealth to hospitals.

During the recent virtual hearing of the House committee on health, Philippine Hospital Association president Dr. Jaime Almora said the private hospitals have P86,079,590,987.21 worth of claims to PhilHealth from January 2020 to June 2021, of which about P26 billion are still being processed while P46.6 billion were returned to hospitals and around P13.8 billion were denied. 

Almora decried the “arbitrary denial of payment, resulting in losses to hospitals is not only unlawful but also morally wrong.”

PhilHealth, for its part, said it found that there were abuses in the hospitals claiming probable COVID-19 cases.

With this, the state insurer said it finds it imperative to implement measures to ascertain the security and sustainability of funds entrusted to it.

Under the Circular No. 2021-0013, any of the following shall be a ground for the issuance of TSPC: fraudulent acts, unethical acts or abuse of authority.

A healthcare provider subject to investigation shall be issued a notice of findings and shall be required to file an answer within a non-extendable period of three days from receipt of notice.

If the answer to the notice of finding lacks merit or no answer has been filed within the prescribed period, a TSPC order shall be recommended in the investigation report.

A TSPC order shall be approved by the president and CEO of PhilHealth. If no action is taken within 30 days from receipt of recommendation the TSPC order shall be deemed approved.

Then, a notice of TSPC order shall be issued by the PhilHealth vice president or regional vice president to the healthcare provider indicating the effectivity date of the order.

“All healthcare providers can rest assured that this policy will be enforced with respect to due process and existing rules and regulations,” PhilHealth said.

“Likewise, this policy will affect only providers engaged in fraudulent acts against the funds entrusted to the Corporation by its members,” it said.

The state insurer assured its members and accredited providers that all good claims shall not be affected by this policy.—LDF, GMA News