Hospital group alarmed over PhilHealth's new circular on claims payment

Aleta Nieva Nishimori, ABS-CBN News

Posted at Aug 21 2021 11:54 AM

MANILA- The Philippine Hospital Association (PHA) on Saturday expressed alarm over an updated PhilHealth circular on the suspension of payments of claims (TSPC), saying the move will not only affect health care providers but patients as well.

“Nakakabahala sa amin 'yan dahil inilabas nila 'yung temporary suspension of payments of claims na circular at a time na kami ay nag-aanatay na mabayaran sa malaking utang sa amin simula pa noong lumabas itong COVID pandemic. Last year pa 'yan malaking amount hindi nababayaran ng PhilHealth sa ating mga providers sa COVID,” said PHA president Dr. Jaime Almora.

(We are alarmed over this issuance of a temporary suspension of payments of claims at a time when we are waiting to be paid for their huge debt to us since the start of the pandemic. PhilHealth has yet to pay the huge debt they owe to providers.)

On Friday, the state insurer issued Circular 2021-0013 on the guidelines on TSPC. PhilHealth said it is strengthening its measures to ensure the rational use of funds by detecting potential fraud or reimbursement abuse through dubious claims.

PhilHealth said the circular which covers health care institutions, provider networks and health care professionals “establishes guidelines on the issuance of TSPC as payment preventive measure against health care providers that are subject of an 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.”

Almora said the circular comes at a time when the country is in the middle of the coronavirus pandemic, health workers are already suffering and lacking benefits promised them, and hospitals have ran out of funds to upgrade their facilities.

“Kami po natatakot na baka sa meeting na darating sasabihin nila na kaya hindi nila binabayaran ang mga claims dahil fraudulent claims,” he said.

(We are afraid that maybe in the next meeting they will say that they will not pay the claims due to fraudulent claims.)

The group claims that PhilHealth owes private and public medical facilities some P20 billion in COVID-19 claims. This resulted in the hospitals' loss of trust and confidence in its transactions with PhilHealth, Almora said in a previous interview.

Shirley Domingo, PhilHealth’s Vice President for Corporate Affairs and the agency's spokesperson, said the policy has been in place since 2016. The circular introduced new provisions to ensure due process is observed before any TSPC is finally issued “to allay fears of alleged arbitrary investigations among our providers.”

“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,” Domingo said in a statement posted on Facebook.

In the circular, PhilHealth said that before a TSPC is issued, a notice of findings will be given to a health care provider by the vice president or regional vice president or the Fact Finding Investigation and Enforcement Department as part of the investigation process. 

The healthcare provider is given a non-extendable period of 3 days to file an answer. However, if the answer lacks merit or no reply was made, a TSPC order shall be recommended in the investigation report. The order shall be approved by the PhilHealth President and CEO. It shall be deemed approved if no action is taken in 30 days from receipt of the recommendation.

The TSPC order will cover all affected identified claims already with PhilHealth that have not been paid including those refiled, under motion for reconsideration and/or appeal, and claims that will be submitted to PhilHealth after the issuance of the TSPC order.

However, claims in cases that are still pending with the Prosecution Department of Arbitration Office will not be covered by the policy.

The extent of the TSPC may cover suspected claims of ghost patients or those non-admitted or non-treated patients and for specific conditions or procedures.

The circular added that the TSPC will not exceed 120 calendar days but can be extended up to 90 days for further investigation.

PhilHealth said it would continue to receive and process all claims from health care providers issued with TSPC orders. But payments shall be put on hold pending investigation or resolution of the case.

The TSPC order may be lifted after the effectivity period or when no evidence of an offense was found to have been committed by the healthcare provider.

Domingo assured health care providers that the policy will be enforced with respect to due process and existing rules and regulations. She added that the policy will only affect providers engaged in fraudulent acts against the funds entrusted to PhilHealth by its members. 

“Sana nga ay totoo na mabigyan ng unbiased and fair evaluation ang mga claims,” said Almora.

(Let’s hope that claims will be given an unbiased and fair evaluation.) 

Almora said that management of COVID-19 is an evolving process and doctors are doing their best so they could to treat patients.

The Philippines on Friday logged its highest ever daily infections at 17,231. This comes exactly 2 weeks since the enhanced community quarantine (ECQ) was imposed in virus hotspot Metro Manila and some provinces. 

The government has decided to downgrade it to modified ECQ (MECQ) starting this weekend until the end of the month.


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