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We are serious about curbing fraud, and we will not hesitate to prosecute those who are found guilty of inappropriate medical practices.

We called for today’s Press Briefing for two major reasons: first, to inform and educate our members about the need to exercise their rights as patients; second, to emphasize what we are currently doing to stop fraud and protect the fund which our members have entrusted to us for their health insurance coverage.

Every Filipino patient has rights that he must invoke when undergoing medical treatment. This set of rights is intended to protect the patient from inappropriate medical practices that can endanger his life, or result to more harm than good.

Guardians of Health Insurance Fund

Being the country’s largest purchaser of health services, we are committed to fight for the rights of our members who are recipients of medical care in institutions that we have partnered with, nationwide. It is our duty to ensure that our members receive medical care services of the right kind and of the highest quality at all times.

At the same time, we must protect the health insurance fund from fraudulent practices of even just a few medical practitioners or institutions that potentially taint the medical industry. When there is clear manifestation of deception towards unlawful gain, these practices become fraudulent. The approaches may vary, but the bottomline is, there is an obvious, deliberate effort to defraud government of millions of pesos through unlawful acts.

We seek media’s help in cautioning our members against health care providers that may have been taking advantage of the benefit packages that we are providing to our members.

Let me emphasize that we are taking a pro-active role in curbing fraud, with our members’ best interest in mind. We do not hesitate to apply what is within our powers, such as suspending or revoking the accreditation of our providers, imposing fines, filing cases and even stopping the release of benefit payments for providers whose claims are being investigated.

In fact, we have just issued the STOP-Claims (Suspension of Transactions on Payments of Claims) orders on all claims filed by two (2) eye centers, pending the results of a thorough validation and investigation on the legitimacy of these claims. We have issued a similar order last year against a hospital in the North. This move is in accordance with the provisions of our Implementing Rules and Regulations which states that "All completed claims, except those under investigation, must be paid within 60 days."

One of these two (2) eye centers, which I can mention later on, received close to P170 million for 11,000 claims last year. This center has a patient who lost her eyesight on the operated eye the day after surgery was done by a doctor whom we have actually suspended due to unethical practices. It has a particularly high volume of patients due to its marketing activities – also called "hakot" wherein the center actively seeks out PhilHealth members to operate on and who may not necessarily be sick patients, after all. The other center received more than P150 million in benefit payments and has three (3) doctors with more than 1,000 cases of fraud filed by the eye center, no less.

Educating our members

Our partners in information dissemination, this is not about eye centers nor of cataract surgeries alone. It is about putting a stop to fraud, abuses and unscrupulous characters wanting to earn illegally at our expense. Matakot po tayong lahat sa “hakot” dahil hindi dapat ito ginagawa ng ating mga medical providers, at ipaalam natin sa ating mga kapwa-PhilHealth members na may tamang gamutan sa bawa’t karamdaman. Hindi ho dahil inaalok nang libre ang serbisyo medikal ay nakatitiyak na ito ay kalidad na serbisyo. This is a call to keep unethical doctors and abusive facilities from further manipulating and exploiting PhilHealth and its members. This is about governance and making sure that everyone behaves appropriately so that we can manage resources to benefit many.

Call to action

Let us remain vigilant about potentially fraudulent practices in the health sector. Report to us any and all incidents of fraud and abuses. If your name as a doctor is being used for illegal activities, report that to us.

If your name as a PhilHealth member is used to claim for admissions that never happened, report that to us. If you are being made to undergo medical procedures without your informed and written consent, tell us about it. Every amount that we save from fraud and abuses can be used to improve our benefit packages and make these packages beneficial for more PhilHealth members. (END)

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