The bridge between the Philippine Health Insurance Corp. (Philhealth) and hospitals is bound to collapse, hospital and medical groups warned, after the state run insurance company temporarily suspended payments of claims to some health care providers.
In a joint statement, the Private Hospitals Association of the Philippines (PHAP), the Philippine Medical Association (PMA), and the Philippine Hospital Association (PHA) said there were “serious cracks” in the the bridge between them and PhilHealth caused by a feeling of mistrust on the part of the state insurance agency.
"The bridge is bound to collapse," the hospitals associations and the medical group said. "Maybe it is time to review the engagement with PhilHealth and level the playing field.”
The country's state insurer temporarily stopped payment of claims of hospitals and other health care providers that are under suspicion of fraud.
Several hospital groups said they will consult their members on whether to sever their affiliation with PhilHealth.
On Friday, PhilHealth issued Circular 2021-0013, which set guidelines on the issuance of Temporary Suspension of Payment Claims or TSPC against health care providers and claims under probe for fraud, unethical acts, and abuse of authority.
The TSPC will not exceed 120 calendar days, but it may extend for another 90 days if the case warrants further investigation.
PhilHealth noted the investigation was a way to control those seeking to take advantage of the system.
But health care providers rejected the circular and the allegations hurled against them, saying these lacked basis.
“The health care providers view this baseless circular as another ploy to deny or delay the payment of claims,” the groups said.
Earlier, PHA disclosed Philhealth has been indebted to health care providers to the tune of P86 billion.
The PHA, PMA, and PHAPi, however, said its members will continue to serve the PhilHealth-covered patients as long as their members' contracts with PhilHealth are still in force.
In a statement, PhilHealth said the policy has been in place since 2016 and the latest circular only added provisions that would "ensure that due process is observed" in the issuance of the TSPC.
It assured providers that "good claims" will be untouched.
Shirley Domingo, Philhealth vice president, said the latest circular was issued in the spirit of proper fund management and fraud control. She said fraud control is a basic tenet in managing funds. "Hence, PHilhealth finds it imperative to implement measures to ascertain the security and sustainability of funds entrusted to it."
She also assured all health care providers that the policy will be enforced with respect to due process and existing rules and regulations.
But PHA president Dr. Jaime Almora said several hospitals were alarmed by the new PhilHealth circular.
He emphasized they are particularly afraid that their COVID-related claims will be declared "fraudulent" and the tag could unfairly taint the reputation of hospitals.
The PHA chief also said some of their member-hospitals found the new PhilHealth circular “too sweeping.”
"Our hospitals are connecting the temporary suspension to the numerous unpaid claims. So what does this mean, they don't want to pay by using 'fraudulent' claims as an excuse?
“We cannot help but connect the circular with the non-payment of the bills,” he added.
Despite the controversy, he said they will still admit COVID-19 patients, but he appealed to PhilHealth to give “financial risk protection” to hospitals.
Albay Rep. Joey Sarte Salceda said the PhilHealth circular had good intentions, but it may hamper the COVID-19 response if it is not properly implemented.
“In theory, it’s a good idea to crack down on insurance fraud, especially as our resources are scarce. In practice, if they implement this the way tax audits are done, that is, every small claim is subject to the same level of scrutiny, then it could delay the flow of critical financial resources towards COVID-19,” Salceda said.
Salceda said that he hopes Philhealth will spend its financial resources wisely.
He said unless PhilHealth takes a risk-based approach in which cases are prioritized to determine which are worth examining, the circular could delay the flow of much-needed funding towards struggling government COVID-19 treatment centers.