SC warns healthcare institutions against abuses on claims for PhilHealth benefits

Published August 24, 2021, 4:57 PM

by Rey Panaligan 

Supreme Court (SC)

The Supreme Court (SC) has warned accredited healthcare institutions “from employing unscrupulous methods like actively recruiting patients just so they could avail of PhilHealth (Philippine Health Insurance Corporation) benefits.”

It also exhorted PhilHealth members and its officials “to act with prudence and without any corrupt motives” and that “medical practitioners should not also allow themselves to be drawn into this unethical practice.”

The SC’s warning and exhortation were contained in a decision that reversed the 2014 ruling of the Court of Appeals (CA) upholding the trial court’s order which ordered PhilHealth to reimburse Urdaneta Sacred Heath Hospital (USHH) of P1.47 million for cataract treatments and surgeries done to its patients.

In a decision made public last month and written by Associate Justice Ramon Paul L. Hernando, the SC ruled that USHH failed to disprove that it employed “seekers” in order to gather patients for the free cataract screening who in tum sought treatments in the hospital using their PhilHealth benefits, whether as members or beneficiaries.

Associate Justice Ramon Paul L. Hernando

In the reversed CA decision, the appellate court ruled that contrary to PhilHealth’s contention, USHH’s claims for surgeries or treatments done from Dec. 2008 up to March 2009 were not performed during medical missions as declared by PhilHealth’s own fact-finding verification report.

The CA’s decision prompted PhilHealth to elevate the issue before the SC. It pointed out that USHH clearly violated the laws, rules and regulations under the National Health Insurance Act of 1995 (NHI Act) as the treatments and surgeries were actually performed in the course of medical missions.

PhilHealth told the SC that some of the claims of USHH were still subject for review, investigation and processing and that administrative cases had been filed against the hospital and several of its affiliated ophthalmologists for violations of the provisions of NHI Act.

It also told the SC that during the period involved in USHH’s claims, the hospital and several of its physicians conducted the screening of patients from several municipalities in Pangasinan, and it employed “seekers” who travelled from one barangay to another to “recruit” patients with cataract problems.

Granting PhilHealth’s petition, the said that the hospital and its personnel involved in cataract screenings and subsequent operations or treatments violated PhilHealth’s rules that prohibit cataract operations during medical missions.

“While a cataract screening is different from an operation, reason dictates that there would have been no surge in the number of cataract operations in USHH had there been no ‘free screening’ in the first place,” the SC said.

It said: “These findings are too significant to ignore. USHH did not specifically dispute these claims or even attempt to clarify why it suddenly had several cataract patients. USHH’s silence on this matter is highly suspect, which suggests that it indeed devised ways to circumvent the directives of PhilHealth, specifically Circular Nos. 17 and 19, series of 2007.”

Circular No. 17 provides that “PhilHealth shall thereby discontinue the compensability of claims for cataract operations performed during medical missions and other recruitment schemes for cataract surgery” while Circular No. 19 states that “all claims for cataract surgeries shall not be compensated if performed during medical missions.”

The SC also said:

“The present pandemic already highlighted the anomalies, flaws, and limitations of our public health system. Philhealth’s financial resources, and that of our nation as a whole, is already stretched to its limit.

“The present situation should inspire us to rise above ourselves and focus on our nation’s survival as a whole.

“The hardships brought about by the pandemic should not strip us of our humanity, or destroy or defeat our core values, but rather serve as a stimulus for positive changes within ourselves and in our nation.

“This should be a platform to better ourselves and an opportunity to craft and implement needed reforms in our public health care system. Indeed, this is what our policy makers envisioned in the first place.

“At this juncture, it is well to remind accredited healthcare institutions to deal with PhilHealth responsibly, honestly, and with integrity and refrain from employing unscrupulous methods like actively recruiting patients just so they could avail of PhilHealth benefits.

“Likewise, Philhealth members and its officials are similarly exhorted to act with prudence and without any corrupt motives.

“Medical practitioners should not also allow themselves to be drawn into this unethical practice.

“WHEREFORE, the instant Petition for Review on Certiorari is hereby GRANTED. The assailed Decision dated March 21, 2014 and Resolution dated Sept. 17, 2014 rendered by the Court of Appeals in CA-GR. CV No. 100477 are hereby REVERSED and SET ASIDE. The Complaint of Urdaneta Sacred Heart Hospital is DISMISSED for lack of merit.”