PhilHealth Strengthens Reforms to Block Possible Fraud in Benefits’ Utilization

The Philippine Health Insurance Corporation (PhilHealth) said on Wednesday it is putting in place stringent measures to ensure that it will curtail any possible fraud and abuse on the utilization of PhilHealth benefits in the future.

“The benefit packages are being studied so that safety parameters and controls can be put in place to promote patient safety and fraud mitigation,” said Dr. Israel Francis A. Pargas, PhilHealth OIC-Vice President, Corporate Affairs Group.

Dr. Pargas added that public education to inform PhilHealth members about their rights as patients and about unethical and illegal practices such as solicitation with inducements and kickbacks is also being undertaken.

He also disclosed that in a recent meeting, the PhilHealth Board approved the filing of administrative cases at the Professional Regulations Commission and the publication of cases in media for all PhilHealth providers who have abused the privilege of PhilHealth benefits’ utilization.

According to him, 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 of PhilHealth benefits.

In addition, Dr. Pargas said they started a proactive approach to mitigate fraud by strengthening the Risk Management Committee to identify potential areas of risk and to put forward action steps.

He also said that the Corporation’s enterprise architecture and dash board have likewise been made to monitor the benefits availed of and the movement of funds.

“It has also beefed up its Information Security program,” Pargas said.

He further said that blocking leakages 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 percent 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 will be guaranteed with a fixed and reasonable co-payment.

The other diseases that make up the 20 percent 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,” Dr. Pargas said.

It can be recalled that controversies on fraud in connection with PhilHealth payments to health care providers first came to light in May 2015.

This resulted in a Senate investigation in the latter part of 2015 that brought to the limelight even more details about the said existing problem, particularly among eye centers and ophthalmologists.

Since then, PhilHealth has 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 percent of the population.

Administrative and criminal cases have been filed not just against eye centers and eye doctors, but all other health care providers who have abused the privilege of PhilHealth accreditation to safeguard the funds from abuses.

In the last eight months since October 2015, the PhilHealth’s Committee on Appealed Administrative Cases (CAAC) decided 111 cases, and as of June 20, 2016, had a zero backlog.

PhilHealth benefit payments have almost doubled in less than three years.

In 2015, PhilHealth paid PHP97 billion in benefits from PHP55.5 billion in 2013.

The shift from fee for service to Case Rates also streamlined the claims payment and reduced turnaround time by 50 percent.

However, much still has 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 diseases that burden the country most, and curb fraud.(PNA) SCS/LSJ