PhilHealth denies alleged overpayments that cost billions


Posted at Jun 10 2019 11:55 AM

Philhealth Local office at Mother Ignacia Street, Quezon City. Mark Demayo, ABS-CBN News

MANILA- The Philippine Health Insurance Corp (PhilHealth) on Monday denied alleged overpayments that resulted in over P100 billion in losses, following reports of fraudulent claims being made to the agency.

PhilHealth deputy spokesman Rey Baleña said the firm practices a case rates payment system, wherein a fixed rate for particular diseases or treatments is followed.

"We don't consider it as overpayment because under the case rates regime that's the way we pay our providers, the case rates, wherein there are predetermined rates already that we pay for a certain disease or illness or procedure," he told ANC's "Early Edition."

Baleña explained that under the system, hospitals can "win in some, and lose in some," meaning hospitals can earn profits under the system and can also incur losses in a case-to-case basis.

"We really stand by our system that it's not overpayment. It's efficiency gain," he said.

PhilHealth has been under fire following an alleged "ghost" claim for dialysis.

Baleña said "ghost" claims are a loophole for PhilHealth, since the agency has no way to verify if a member is still alive unless it is reported to them.

"Dapat maintindihan natin na kung hindi mai-report sa PhilHealth that a member already died, wala kaming way to update our database that the patient has already expired," he said.

(We have to understand that unless it is reported to PhilHealth that a member already died, we have no way to update our database that the patient has already expired.)

President Rodrigo Duterte on Saturday said he would "reorganize" the government health insurance firm as he noted that losses of some P100 billion were "totally, totally unacceptable."

Baleña also disputed the reported P100 billion in losses due to fraudulent claims, saying data from PhilHealth show that losses amount to P300 million.

The PhilHealth spokesman also assured the public that losses due to fraud can be recovered by the agency, noting that legal actions are undertaken against hospitals.

Baleña said PhilHealth now practices a medical pre-payment review system to verify claims being made by health providers and hospitals.