The Philippine Health Insurance Corporation (PhilHealth) said it is implementing a "temporary suspension of payment of claims" (TSPC) against healthcare providers (HCPs) that are "subject of investigations pertaining to fraudulent” claims.
This is based on the state health insurer's Circular No. 2021-0013 that was released on Friday, Aug. 20
PhilHealth said that TSPC is the “conditional stoppage of payment for claims undergoing investigation. It is not a penalty but a preventive measure to avoid the loss or wastage of funds due to fraudulent acts, unethical acts, and abuse of authority.”
“(It is) a payment preventive measure against HCPs that are subject of investigation based on the credible and verifiable report by the Corporation or other duly authorized government agencies, owing to apparent and probable presence of fraudulent act, unethical practices, and /or abuse of authority,” it added.
The Circular was issued in the “spirit of proper fund management and fraud control,” said PhilHealth Vice President for Corporate Affairs Shirley Domingo in a statement on Friday, Aug. 20.
“This policy has been in place since 2016 (PhilHealth Circular 2016-026). With this new Circular, the Corporation introduced additional provisions that would ensure that due process is observed before any TSPC is finally issued so as to allay fears of alleged arbitrary investigations among our providers,” said Domingo.
“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 added.
PhilHealth said it shall “continue to receive and process all claims from the HCP with TSCP Order. However, payment shall be put on hold pending investigation or resolution of cases.”
“The TSCP Order may be lifted either by reason of the expiration of the 120 calendar day effectivity period, unless otherwise extended, or when, after investigation, no evidence of an offense was found that the concerned HCP has committed,” the state health insurer said.
“Payment of claims subjected to investigation but cleared from fraud and/or irregularities shall be released after the TSPC period,” it added.
Domingo said that due process is being strictly followed with regards to the implementation of TSPC.
"All health care providers can rest assured that this policy will be enforced with respect to due process and existing rules and regulations. Likewise, this policy will affect only providers engaged in fraudulent acts against the funds entrusted to the Corporation by its members," she said.
"PhilHealth assures its members and accredited providers that all good claims shall not be affected by this policy," she added.