The Court of Appeals (CA) has reminded healthcare institutions to deal with the Philippine Health Insurance Corporation (PhilHealth) “responsibly, honestly, and with integrity, and to refrain from employing unscrupulous methods like actively recruiting patients just so they could avail of benefits.”

At the same time, the CA exhorted PhilHealth members and its officials “to act with prudence and without any corrupt motives” and medical practitioners “not to allow themselves to be drawn into this unethical practice.”

The CA’s reminder and exhortation were contained in its decision that denied the appeal of Dr. Alberto M. Castro who challenged the April 11, 2019 ruling of the PhilHealth board which found him guilty of 17 counts of administrative offense of breach of warranties of accreditation under Republic Act No. 7875 or the National Health Insurance Act.

Castro was penalized with six months suspension of accreditation with PhilHealth and a fine of P20,000. He was also ordered to restitute the benefit claims paid by PhilHealth. He the ruling before the CA.

The activities of Castro were unearthed after lawyer Yasser Ismael A. Abbas, head of PhilHealth’s legal services unit in the National Capital Region and Rizal, conducted a regular monitoring of the Quezon City Eye Center.

Abbas found that Castro and several other doctors were engaged in the recruitment of patients for cataract operations. He recommended the suspension of the doctor’s claims with PhilHealth.

Thereafter, PhilHealth’s Fact-Finding Investigation and Enforcement Department (FFIED) conducted its own probe. It selected 12 of Castro’s patients who admitted that free check-ups were conducted in their barangay. Those patients were PhilHealth members.

It was found that subsequent operations were conducted by Castro in a hospital facility, and the patients were brought to the hospital on free transportation.

Formal complaint was recommended by FFIED against Castro for violations of PhilHealth Circulars 17 and 19 issued in 2007.

Circular 17 mandated the discontinuance of compensability of claims for cataract surgery performed during medical missions and thru other recruitment schemes. Circular 19, on the other hand, issued the implementing guidelines for Circular 17.

In his defense, Castrol told PhilHealth that the medical missions which were dubbed as recruitment activities were initiated by the provincial government of Bulacan which invited him and the other ophthalmologists.

He pointed out that they assisted patients whether or not they were members of PhilHealth to help the less fortunate.

In filing the charges and finding Castro guilty of administrative offenses, PhilHealth said that it was highly questionable that patients were transported for free in going to and from Quezon City Eye Center, when the operation could have been performed in one of the government hospitals in Bulacan or in Monte Falco Hospital where the petitioner has a clinic.

PhilHealth also pointed out that the prohibition to recruit and solicit patients include those programs sponsored by the Philippine Ophthalmology Association (POA) and the local government units.

In denying Castro’s petition, the CA cited FFIED’s discovery of circumstantial evidence which supported the circumvention of Circulars 17 and 19 by Castro like “all the patients who were interviewed came from Bulacan, although different municipalities; almost all of the patients were transported to and from the place of operation, free of charge; and the interviewees are all members or beneficiaries of PhilHealth.”

“These circumstantial evidence, when taken together, clearly prove that indeed Dr. Castro violated Circular Nos. 17 and 19, series 2007. While it is true that the cataract operations were not performed during the medical missions participated by Dr. Castro, reason dictates that there would have been no surge in the number of cataract operations had there been no ‘free screening’ in the first place,” the CA said.

The CA also said in its decision written by Associate Justice Alfonso C. Ruiz II and concurred in by Associate Justices Apolinario D. Bruselas Jr. and Ronaldo Roberto B. Martin:

“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.

“WHEREFORE, the present petition is DENIED. The April 11, 2019 Decision of the PhilHealth Board of the Philippine Health Insurance Corporation is AFFIRMED. SO ORDERED.”

TAGS: #Cour of Appeals #PhilHealth