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PhilHealth fines, penalizes erring hospitals September 11, 2018

State agency Philippine Health Insurance Corporation (PhilHealth) said that it is now imposing fines against erring hospitals instead of outright suspension or revocation of their accreditation in order to ensure that members continue to access health services and avail themselves of their benefits even if these facilities are being made to account for their fraudulent practices.

In accordance to its Board Resolution No. 2334, s-2017 and its implementing guidelines as contained in Corporate Order 2018-0039, PhilHealth can now impose maximum fines on hospitals liable for offenses in administrative cases with PhilHealth.

PhilHealth said that they have at least 71 hospitals nationwide with a combined total of 298 cases currently in arbitration due to various violations such as fraudulent acts and breach of warranties of accreditation/performance commitment, filing of multiple claims, misrepresentation by furnishing false or incorrect information, and claiming for non-admitted patients, among others.

The said policy is in keeping with its commitment to curb fraud and protect its funds from abuse and pilferage without interrupting access to health care services. “We recognize that suspending or revoking a hospital’s accreditation will result to members not being able to avail of their benefits when they or their dependents are admitted in these facilities,” PhilHealth Acting President and CEO Dr. Roy B. Ferrer explained.

However, PhilHealth clarified that their policy of meting maximum fines does not apply to cases against health care professionals; cataract cases through recruitment schemes; cases that are already on appeal with the Courts; and to recidivists or those who have been repeatedly sanctioned for the same offense.

"We are not prevented from suspending or revoking hospital accreditation if truly warranted by circumstances," Ferrer asserted, saying that from 2010 to present they have suspended at least 31 hospitals and revoked the accreditation of another two facilities for violations ranging from extending period of confinement, misrepresentation, claiming for non-admitted patients, among many others.

It was also revealed that for the period 2015 to June 2018, it has detected some 2,000 claims that are tainted with fraud amounting to P17.8 million. For cataract cases due to recruitment schemes alone, a total of 5 facilities and 11 health care professionals with a combined total of 3,673 cases are now up for decision.

The state agency also said that it recently won cases in the Supreme Court and in the Court of Appeals on these cataract cases, upholding its actions against erring providers.

"This should serve as a warning to those who are still into active recruitment of unsuspecting cataract patients who are operated on even in very poor conditions in order to sap unwarranted payments from the National Health Insurance Fund." Ferrer said. END (Rey T. Baleña)

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PhilHealth fines, penalizes erring hospitals