PhilHealth suspends payments for claims under probe

MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) is suspending payments to hospitals and medical professionals with reimbursement claims under investigation for fraud – a move that may prompt private hospital organizations to “disengage” from the state-run health insurer.

Under PhilHealtlh Circular No. 2021-0013 issued yesterday, a temporary suspension of payment of claims is in effect for 120 days. TSPC is a “conditional stoppage of payment for claims undergoing investigation.”

PhilHealth president and CEO Dante Gierran said the measure has been employed “in order to assure rational use of funds by detecting potential fraud or reimbursement abuse through dubious claims.”

“It is not a penalty, but a preventive measure to avoid the loss or wastage of funds due to fraudulent acts, unethical acts and abuse of authority,” the PhilHealth said.

It clarified that it shall continue to receive and process all claims from health care professionals (HCPs) with TSPC Order. However, payment shall be put on hold pending investigation or resolution of cases.

The TSPC may be lifted upon the expiration of 120 days, unless otherwise extended to warrant further investigation of not more than 90 days or upon the resolution of the case.

‘Arbitrary and unjust’

Dr. Jose Rene de Grano, president of the Private Hospitals Association Inc. (PHAPi), described the move as “arbitrary and unjust,” considering that PhilHealth still owes hospitals P86 billion in unpaid reimbursement claims.

“What PhilHealth (officials) are doing to hospitals is too much,” De Grano told The STAR. “Imagine on suspicion of fraud, they will suspend the payment of all of your claims – past and future – even the COVID-19 cases amounting to P86 billion. What will happen to us?”

He underscored that PHAPi supports PhilHealth’s move against unscrupulous HCPs but this should not be done at the expense of the innocent ones.

De Grano added the new circular will compromise the services that they render to their patients, especially in this time of pandemic.

‘Disengaging’

De Grano said he and Dr. Jose Almora, president of the Philippine Hospitals Association (PHA), have discussed the matter and they are looking at “disengaging from PhilHealth.”

“That means we will still accept PhilHealth members but they will have to pay from their own pocket. They cannot use their PhilHealth (benefits) for the meantime,” he said.

The two leaders are set to further discuss this plan with their members although many have already agreed to it.

De Grano added that PHAPi lawyers are studying legal action against PhilHealth because they were not consulted about the circular.

In a separate statement later in the day, PhilHealth spokesperson Shirley Domingo said that the policy stipulated in the circular is nothing new and it has been in place since 2016.

“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,” she said.

Domingo added that the circular was issued “in the spirit of proper fund management and fraud control.”

“Fraud control is a basic tenet in managing funds. Hence, PhilHealth finds it imperative to implement measures to ascertain the security and sustainability of funds entrusted to it,” she said.

She assured HCPs that the policy “will be enforced with respect to due process and existing rules and regulations.”

“Likewise, this policy will affect only providers engaged in fraudulent acts against the funds entrusted to the corporation by its members,” Domingo said. “All good claims shall not be affected by this policy.”