The Court of Appeals (CA) has urged healthcare institutions not to resort to unscrupulous
methods just to avail of the benefits being provided by the Philippine Health Insurance Corp. (Philhealth).
In an 11-page decision penned by Associate Justice Alfonso Ruiz II, the CA’s Fifth Division also enjoined Philhealth members and its officials “to act with prudence and without any corrupt motives” in performing their duties.
“Medical practitioners should also not allow themselves to be drawn into this unethical practice,” the CA said.
The appellate court made the reminder as it denied the petition filed by Dr. Alberto Castro seeking to set aside the April 11, 2019 decision of the Philhealth board affirming the October 26, 2018 decision of the arbitration office of Philhealth finding him guilty of 17 counts of administrative offense of breach of warranties of accreditation under Republic Act 7875 or the National Health Insurance Act.
“The present pandemic already highlighted the anomalies, flaws, and limitations of our public health system. Philhealth’s financial resources, and that 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 CA noted.
Castro’s illegal activities were discovered after lawyer Yasser Ismail Abbas, head of the Philhealth’s legal services unit in the National Capital Region and Rizal conducted regular monitoring in Quezon City Eye Center.
After several days of investigation, Abbas found out that Castro along with several other doctors were engaged in the recruitment of patients for cataract operations, which is detrimental to the interest of Philhealth.
Abbas recommended the suspension of their claims with Philhealth pending further investigation.
Acting on the recommendation of Abbas, Philhealth’s Finding Investigation and Enforcement Department (FFIED) conducted its own probe.
It selected 12 patients of Castro who admitted that a free initial check up were conducted in their respective barangays provided that the patient is a Philhealth member.
The subsequent operations were conducted by Castro in a hospital facility, and the patients were brought to the hospital via free transportation.
The FFIED recommended the filing of a formal complaint against Dr. Castro and Quezon City Eye Center for violation of Philhealth Circular Nos. 17 and 19 Series of 2007.
Castro denied the accusations and insisted that the medical missions labeled by Philhealth as recruitment activities were initiated by the provincial government of Bulacan.
Castro said he and several other ophthalmologists in Bulacan were invited. He added that all patients, whether Philhealth members or not, were assisted during the medical missions and that he joined the free eye consultation purposely to help the less fortunate.
However, the Philhealth declared 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 held that the prohibition to recruit and solicit patients includes those programs sponsored by the Philippine Ophthalmology Association (PAO) and local government units.
It concluded that Philhealth profited from the operations incurred by its members while the non-members paid from their own pockets.
In upholding the ruling of Philhealth, the appellate court did not give weight to Castro’s argument that Philhealth Circular No. 19 only states the guidelines to determine whether cataract surgeries in medical mission are compensable, thus, it erred that all cataract surgeries in relation to medical missions are non-compensable.
“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 pointed out.