PhilHealth payment freeze on doubtful claims to hamper hospitals’ operations –Salceda

While the intention was good, the new directive by the Philippine Health Insurance Corporation (PhilHealth) to temporarily halt payment to hospitals with questionable claims could hamper their COVID-19 operations, Albay Representative Joey Salceda said.

The chairperson of the House ways and means committee instead pitched a “risk-based” approach as the state insurer looks into the claims.

“In theory, it’s a good idea to crack down on insurance fraud, especially as our resources are scarce. In practice, if they implement this the way tax audits are done, that is, every small claim is subject to the same level of scrutiny, then it could delay the flow of critical financial resources towards COVID-19,” Salceda said in a statement.

PhilHealth on Friday 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.

Salceda warned, however, that “unless a risk-based approach is taken,” the circular could delay the flow of much-needed finances towards government treatment centers challenged by the pandemic.

By risk-based approach, Salceda said he meant “the prioritization of cases that are worth examining thoroughly.”

“The legal profession calls the doctrine aquila non capit muscas. The eagle does not catch flies. In other words, they have to go after the cases that really pose a threat to the system. Otherwise, the system might spend so much time investigating small cases that it misses out on the big ones,” he said.

The lawmaker pointed out that the circular defines the claims it will suspend payment for as those “that are subject of investigation based on credible and verifiable report by the Corporation or other duly authorized government agencies, owing to apparent and probable presence of fraudulent act, unethical practices, and/or abuse of authority.”

“That definition strikes me as a bit too broad. And it doesn’t appropriately ascribe responsibility. What if it was the patient and not the institution that defrauded the system? Will payment of claims to the institution be suspended just as well?” he said.

According to the circular, it was issued “in the spirit of proper fund management and fraud control.”

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

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.