CEBU, Philippines — The Philippine Health Insurance Corporation (PhilHealth) has suspended the accreditation of Adventist Hospital Cebu, Inc. in Cebu City over fraudulent claims.
Adventist (formerly H.W. Miller Memorial Sanitarium and Hospital) on Tres de Abril Street in Barangay San Nicolas is barred from the national health insurance program for three months, starting on August 1.
Aside from the suspension, the said hospital was meted a fine of P10,000.
The suspension and fine stemmed from Adventist’s “misrepresentation by furnishing false or incorrect information and breach of the warranties of accreditation based on Section 144 and 150 of the Implementing Rules and Regulations of Republic Act No. 7875.”
PhilHealth-7 Accreditation Section discovered these following an inspection for accreditation renewal in 2007.
“It was found out that dialysis clinic SouthMed Dialysis Center, Inc. (SMDC), a tenant of the hospital, filed dialysis claims through Miller. Although there was a contract of lease between both facilities, there was no memorandum of agreement stating SMDC as an outsourced service unit of Miller.”
“Through a fact-finding investigation report, PhilHealth 7 Legal Office recommended filing a case to its Head Office against the hospital for misrepresentation by furnishing false or incorrect information,” PhilHealth said in a statement.
In 2009, PhilHealth Head Office’s Prosecution Department filed the complaint about misrepresentation by furnishing false or incorrect information, a violation of PhilHealth Circular No. 17, s-2006, and breach of the warranties of accreditation under Sections 144 and 150 of the Implementing Rules and Regulations of Republic Act 7875.
At least two anomalous benefit claims were made to appear that hemodialysis sessions of a patient were performed at Adventist where in fact were done at SMDC, PhilHealth said.
PhilHealth initially rendered a decision of finding the hospital guilty on two counts of Section 144 and meted the penalties of suspension of accreditation of six months and a fine of P20,000.
It also denied two claims of the dialysis patient but the said hospital filed a Notice of Appeal with Memorandum of Appeal.
The PhilHealth Board in 2013 issued a resolution modifying the Arbiter’s decision. In effect, the penalties were reduced to three-month suspension and a fine of P10,000.
The hospital still as Miller at that time, filed a Motion to dismiss, while Adventist Hospital Cebu, Inc. which took over the operations, assets, and liabilities of Miller, filed a Manifestation with Motion for Reconsideration in 2016, but the same was denied by the PhilHealth Board.
The hospital also filed a petition for review and a motion for reconsideration to the Court of Appeals (CA) but the CA denied the same in 2017. It then filed an appeal to the Supreme Court (SC) but the SC denied the petition of being unmeritorious and affirmed the CA decision.
Finally, last May of this year, PhilHealth-7 Legal Office received the Order and Writ of Execution of the case against Adventist from its Head Office’s Arbitration Department and served the order last June 1 to the hospital’s president.
“The order states that the implementation of suspension of accreditation shall take effect on August 1, 2021, up to October 29, 2021.
The agency advised patients to transfer to other medical centers to be able to avail themselves of benefits.
“Members are advised to seek medical services in other accredited health care institutions as PhilHealth will not receive, process, nor pay any claims from Adventist Hospital Cebu, Inc. in the duration of the suspension of accreditation,” said PhilHealth. — KQD (FREEMAN)