April 20, 2024

■  Hanna C. Lacsamana   

The Philippine Health Insurance Corporation (PhilHealth) has sued those who have been complained for ghost claims and those who have not providing proper service to PhilHealth clients.

Atty. Eric Mandiit, PhilHealth-Cordillera Legal Services Section head, said their office has conducted 129 investigations on irregularities this year, which resulted in the filing of 33 cases in court.

Most of the filed cases involved verified complaints from senior citizen members who were denied of discounts or were not given proper benefits by accredited health service facilities or providers.

PhilHealth has also investigated reports of ghost claims, including one where the applicant claimed to have gave birth in a maternity clinic but upon validation of the claim, it found that the member’s last delivery was in 2010 and had made a claim with PhilHealth in 2016.

Mandiit said they are also dealing with up-casing, where claimants file a higher claim for a lower case rate, those who are not honoring discounts of persons with disability, and multiple filing of claims.

He said there have also been a big number of health care facilities being sued for non-compliance to the No Balance Billing policy and employers who failed to deduct and remit to PhilHealth the contributions of their employees.

“We cannot divulge names but we have filed criminal and administrative cases against big as well as small health facilities, and also members who may have been in connivance with health care providers in not complying with existing laws. We are at the prosecution level,” he said.

Mandiit said the legal division holds weekly checks or visits to health facilities as part of the agency’s constant monitoring across the region to check on health care providers’ compliance to the law and ensure availment of services by members.

He added upon approval, they adjust their strategies to avoid filing of suits such as sending notices to the erring facility or member about the problem and allow them reasonable time to correct their actions or comply with the rules.

PhilHealth Senior Vice President Dominga Gadgad added as much as possible, they also would want to avoid recommending erring hospitals and health facilities for suspension of their PhilHealth accreditation or closure, since this would affect the availability of health services.

“President Ferdinand Marcos, Jr. is trying to instruct that the Universal Healthcare Law be amended so that instead of suspending the accreditation or closing an erring hospital, we can just penalize them so members would still have facilities to go to. This year, many of them natututo naman na, nagco-comply naman sila,” Gadgad said.