AS health-care providers are now rethinking their engagement with Philippine Health Insurance Corp. (PhilHealth) amid the Covid-19 pandemic, the Department of Health (DOH) on Tuesday vowed to look into policy gaps in the implementation of a circular on Temporary Suspension of Payment of Claims (TSPC).
During a hearing of the House Committee on Health, Health Secretary Francisco Duque III said the PhilHealth Circular 2021-0013 will be reconsidered at the board level.
This, after a motion to strongly urge the PhilHealth to review and possibly suspend the circular—without prejudice to any legislative remedy or measure that may be filed in the future—was adopted by the Committee on Health, chaired by Quezon Rep. Angelina Tan.
“It’s a management call actually. We will, however, look at any policy gaps that there might be in the implementation of this cirular,” Duque said.
PhilHealth Circular 2021-013 imposes a temporary suspension of claims for potential fraudulent cases.
“But we are sensitive to the plea [of health-care providers] that we should reconsider this circular and will be taken up at the board level. We just need to establish a legal basis for the actions of the board,” added Duque.
PhilHealth President Dante Gierran, meanwhile, said that all health-care providers can rest assured that this policy will be enforced with respect to due process and existing rules and regulations.
“Let us be clear, the policy does not intend to further burden our partner stakeholders especially during the pandemic. On the contrary, provisions of this policy strengthen due process,” Gierran added.
Review circular
The House Committee on Health on Tuesday strongly urged the state health insurer to review and possibly suspend its circular on TSPC.
The committee adopted the motion of Nueva Ecija Rep. Estrellita Suansing following the concerns of the Philippine Hospital Association (PHA) on Circular 2021-0013.
Health committee chief Tan has also urged the PhilHealth and PHA to immediately resolve their differences.
“PhilHealth says this serves as a preventive measure against healthcare providers that are subject of investigation. The Philippine Hospital Association (PHA), the Private Hospitals Association of the Philippines (PHAPi), and the Philippine Medical Association (PMA), on the other hand, are basically saying, ayawan na. They declared that they were “disengaging” with PhilHealth and warned that the bridge between them and the PhilHealth is ‘bound to collapse,’” Tan said.
“Perhaps, PhilHealth can walk us through the rationale of this circular, especially on its impact on the hospitals and health-care institutions or providers and in the delivery of health services; while the hospital groups can tell us what they see as the possible repercussions of the circular and what compromise can be made so we can move on to address the more pressing concerns of delivering health services to the public amid the Covid-19 health crisis,” she added.
Moreover, PhilHealth acting senior manager Dr. Lambert David said the temporary suspension of payment of claims was merely updated and the recent circular was “issued in the spirit of proper fund management and fraud control.”
David also said PhilHealth is following several guidelines before issuing TSPCs. PhilHealth also assured its members and accredited providers that all valid claims would not be affected by the policy.
According to David, only 0.21 percent of the total 9,496 accredited health-care providers were issued TSPC as of July 31, 2021.
He said PhilHealth will continue to receive and process all claims with TSPC but the payment will be put on-hold.
Under the circular, the PhilHealth has 120 days to investigate unless extended to warrant investigation, which will not exceed 90 days. It will be automatically lifted after 120 days when, after investigation, no evidence of an offense is found.
PhilHealth acting senior manager Ernesto Barbado said their Fact Finding Investigation and Enforcement Department is resolving issues with hospitals with urgency, “that is why we imposed a three-day period for the hospital to answer the allegations of the findings.”
‘Strong doubt’
Philippine Hospital Association President Jaime Almora expressed “strong doubt” on the timing of the release of the TSPC circular.
Almora said the PhilHealth circular was released amid mounting pressure for them to pay hospitals.
From January 2020 to June 2021, he reported a total of P86.1 billion of PhilHealth claims not paid to hospitals—comprising in-process claims with P25.7 billion, return-to-hospital claims with P46.6 billion, and denied claims with P13.8 billion.
“The hospitals and doctors were alarmed. They were naturally piqued. The circular came at a time when hospitals and health-care providers are suffering…from fatigue and exhaustion, financial hardship,” he added.
“The circular was released amid mounting pressure for PhilHealth to pay the hospitals. The pressure is from government-regulating bodies,” Almora added.
With this, Almora said the Board of Directors and Officers of the PHA, the Private Hospital Associations of the Philippines, and the President of the Philippine Medical Associations and other health-care providers, decided to review their engagement with PhilHealth and continue negotiating with PhilHealth.
He said the circular will not only affect health-care providers but patients as well.
Meanwhile, Almora recommended measures to resolve the issues with PhilHealth, including the removal of policies that create too much financial risk for hospitals, administration of due process by hiring a third party composed of medical experts as jury, and installing a representative of health-care providers in the governing board of the PhilHealth.