Salceda

Anti-hospital insurance fraud measures pushed

August 21, 2021 Ryan Ponce Pacpaco 554 views

A HOUSE leader on Saturday warned that the good intention of the Philippine Health Insurance Corporation’s (PhilHealth) order imposing a temporary suspension of claims for potential fraudulent cases could hamper the operations of government hospitals in the fight against coronavirus diease 2019 (COVID-19) if improperly implemented.

Albay 2nd District Rep. Joey Sarte Salceda, chairman of the House committee on ways and means, said Philhealth’s Circular 2021-013 “has good intentions” but at the same time could jeopardize the functions of government hospitals in battling the pandemic since “these hospitals are in need of resources to expand their COVID-19 capacity.”

“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 who proposed the “risk-based” approach to investigate fraud on PhilHealth’s claim.

Salceda said he hopes the PhilHealth will spend its financial resources wisely, as “I am the author of the alcohol excise tax reform, the tobacco excise tax reform, and the Tax Reform for Acceleration and Inclusion, which are keeping Philhealth afloat.”

“I invested significant political capital and fought hard to keep PhilHealth well-funded. So, I welcome any effort to make claims payment more efficient, transparent, and accountable,” Salceda said, adding “but they have to do it right.”

COVID-19 GOVERNMENT HOSPITALS NEED REIMBURSEMENTS

However, Salceda warned that “unless a risk-based approach is taken,” the circular could delay the flow of much-needed finances towards struggling government COVID-19 treatment centers.

Salceda defined risk-based approach as “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.”

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?” Salceda asked.

“In the COVID-19 hospital of the province of Albay, we have around P134 million in unpaid claims, while its P150 million release has already been exhausted due to our seven-fold expansion of COVID-19 capacity. We will have a COVID-19 severe cases treatment capacity of 307 beds, from just 10 when the surge started in May. You can imagine how important early release of PhilHealth claims will be to us,” Salceda added.

“So, as long as it does not close the spigot of necessary resources to fight COVID-19, it is a well-intentioned move. But it is implemented inefficiently, such that they investigate even the smallest of claims, losing time for the really big and dubious cases, it will be trouble for our COVID-19 response,” Salceda said.

ANTI-FRAUD MEASURES NEEDED

Salceda also reemphasized that his proposed PhilHealth Reform Act under House Bill (HB) No. 7578 will mandate a digitized one-patient, one-record system that, along with telemedicine, will help ensure that claims are for genuine cases of medical need.

“The one-patient, one-record portable system, along with telemedicine verification, will help prevent fraud because it will be much harder to defraud something that has a digital trail and can be verified easily,” Salceda said.

Salceda’s proposed reform also designates the Secretary of Finance as the chair of PhilHealth, “as the SOF has the benefit of being the boss of the Insurance Commission, which has the expertise and competence to detect and prevent insurance fraud.”

“I hope the reform can be reconsidered, but for now, I think the Philhealth clarifying that their anti-fraud approach will be risk-based will help,” Salceda added.

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