Fraud in connection with PhilHealth payments to health care providers first came to light in May, 2015. This resulted in a riveting Senate investigation in the latter part of 2015 that brought to the limelight even more details about this serious problem, particularly among eye centers and ophthalmologists. PhilHealth has since taken various concrete measures to curb fraud and to save the funds so that these can be used to improve the benefits of members who are estimated to be around 90-92% of the population.
PhilHealth benefit payments have almost doubled in less than three years. In 2015, PhilHealth paid 97B in benefits from 55.5B in 2013. The shift from fee for service to Case Rates also streamlined the claims payment and reduced turnaround time by 50%. However, much has still to be done to reduce out of pocket payments for members. In order to achieve this, PhilHealth must improve collection efficiency, restructure and prioritize its benefit packages so that it can pay more for the disease that burden the country most, and curb fraud.
In the last 8 months since October, 2015, PhilHealth's Committee on Appealed Administrative Cases (CAAC) decided 111 cases and as of June 20, 2016, has a zero backlog. Several administrative and criminal cases have recently been filed against health care providers, not just among eye centers and eye doctors, but against all other health care providers who have abused the privilege of PhilHealth accreditation. Public education to inform members about their rights as patients and about unethical and illegal practices such as solicitation with inducements and kickbacks, is also being undertaken. In a recent meeting, the PhilHealth Board also approved the filing of administrative cases at the Professional Regulations Commission and the publication of cases in media. The benefit packages are being studied so that safety parameters and controls can be put in place to promote patient safety and fraud mitigation. An Ad hoc committee to investigate non-compliance of Board directives by PhilHealth staff has also been formed. These stringent measures are expected to significantly curtail fraud and abuse.
In addition to the above, a proactive approach to mitigating fraud is to strengthen the Risk Management Committee to identify potential areas of risk and to put forward action steps. The Corporation's enterprise architecture and dash board have likewise made monitoring of benefits availed of and the movement of funds much easier to undertake. It has also beefed up its Information Security program.
All the above are envisioned to plug leakages and will allow PhilHealth to increase the support value for members in terms of better benefits and lower out of pocket payments. In line with this, the Benefits Committee is looking at introducing a Guaranteed Health Package for important disease conditions that cause 80% of the country's disease burden. This means that for these conditions, the poor will be guaranteed truly no balanced billing while those who can afford some co-payment will be guaranteed a fixed and reasonable co-payment. The other diseases that make up the 20% of the disease burden will be subject to a clear and transparent Nomination Process. It is hoped that through all these measures PhilHealth will truly be able to deliver on its mandate of financial risk protection.
