‘Treating PhilHealth members is not a business venture’

Philhealth Facebook page

MANILA — Philippine Health Insurance Corp. (PhilHealth) calls on accredited doctors and hospital facilities to stick and focus to their mission of providing quality health care to patients and make the goal of earning a secondary one.

According to Dr. Israel Francis A. Pargas, PhilHealth Officer-in-charge and concurrent vice president of corporate affairs group, said his fellow doctors should take the lead in proving that treatment of patients was not something like a sort of “business” venture.

“We are calling on doctors and even facilities to exemplify more good examples of treating the patients as a ‘public service for health’ and not just really for the mission of earning money…Kasi kung ang magiging perception sa ating mga doctors ay gusto lang kumita ay hindi maganda..,” said Dr. Pargas in an interview with the Philippines News Agency.

Pargas said that doctors could still earn with dignity as they provide excellent, honest and quality service, which are really needed by the patients availing the benefits of being a PhilHealth member.

He added that his call to the doctors and facilities was part of their effort in protecting the fund of PhilHealth from certain allegedly unscrupulous physicians who commit scams to collect large amount of money from the PhilHealth reimbursements on the case rates that it pays for the patient availing health services.

Background on PhilHealth appeal to doctors to not engage in giving service as a “business”:

Recently, some physicians and even hospital facilities were called for investigation in the Senate due to findings that there were some eye doctors (ophthalmologists) who were involved in the strategy of conducting cataract surgeries just for the purpose of collecting high amount of reimbursement from PhilHealth.

Based on the investigation, it were also learned that some of the innocent victims were senior citizens who were brought to the hospital facility through the “hakot system” of seekers.

The said seekers looked for senior citizens who were PhilHealth members and convinced them to seek eye consultation.

There were also some findings that the patients who undergone cataract surgeries without their knowledge and were just informed that their eyes will just undergo check-up.

Allegedly also, there were also findings in the investigation that the cataract operation led to blindness and the doctor who conducted the surgeries did not have a follow-up with the patient.

What is the role of PhilHealth in the payment of eye surgery case rate?

Cataract surgeries are paid by PhilHealth under the in-patient benefits for every PhilHealth member.

For one eye cataract operation, the PhilHealth is obliged to pay Php 16,000 to the hospital and doctors fees as a health coverage.

If the eye cataract operation will require both eyes, that amount will be doubled and become Php 32,000.

In the senate investigation, there was also a case wherein a newly graduate doctor who performed the eye surgeries had made a claim of Php 36 million in one year alone.

How PhilHealth is safeguarding its fund/protecting member?

The investigation was called for after the monitoring procedure of Philhealth noticed the rise of number of PhilHealth claims for eye cataract surgeries.

In the latest data of the most number of benefit claims for PhilHealth, eye cataract surgeries turned to be in the top four in the list.

“These all came out also upon the monitoring and audit findings which is an integral part of our function,” said Pargas.

He said that PhilHealth itself had agreed for the investigation as a protective mechanism to ensure that funds being paid by every PhilHealth member and funded for by the sin tax revenue are not abused and misused on “questionable claims” and procedures.

He said that aside from the audit system, they were also intensifying their efforts in ensuring that repetition of such incidence would not happen or if ever the one behind it would be punished.

He added that right now they had instituted some reforms like having “visitorial powers” to hospitals and facilities.

“With that visitorial powers, we have staffs checking on hospital charts, medical and financial records for verification,” he said.

He also said that it would also help if a concerned PhilHealth member participated in reporting if they know of some who were involved in planning, execution of scams just to collect higher PhilHealth reimbursements, especially on just ordinary illnesses but turning them as complex ones just to collect big reimbursement from PhilHealth.

What is PhilHealth?

PhilHealth is a health insurance coverage that provides health protection for its members.

It pays the hospitals by reimbursement the professional fees of doctors and other costs incurred the hospitals/facilities such as medicines used for the procedures done to the patient covered through the case rates.

It also pays for the primary care or outpatient benefits such as diagnostic examinations and preventive services.

To be a member, one has to fill-up the PhilHealth Member Registration Form (PMRF) and pay the Php 200 monthly membership fee (Php 2,400.00/year).

Php 200 is a very small amount because it is just equivalent to more than Php 6 a day provision of whole protection for the family members of the eligible member who may be hospitalized for any illnesses.

Indigents who are identified as poor by the National Household Targetting System for Poverty Reduction (NHTS-PR) of Department of Social Welfare and Development (DSWD) are automatically enrolled in PhilHealth.

Senior citizens who are not employed and barangay health workers (BHWs) are automatically PhilHealth members.

Their contributions are shouldered or paid for under the initiatives of the current administration collected from the sin tax revenues as a product of the Sin Tax Law.

At present, 87 percent of the population is covered by PhilHealth.