MANILA, Philippines – Senator Teofisto Guingona III slammed a Philippine Health Insurance Corporation (PhilHealth) committee for the “slow” processing of cases against “abusive” institutions and doctors.

“Kapag walang nape-penalize, walang desisyon na lumabas na final na kailangang parusahan ang isang institusyon na nang-abuso, lumalakas ang loob ng mga eye centers, mga institusyon, na business as usual sapagkat okay lang, walang nangyayari, walang napaparusahan,” the Senate blue ribbon committee chair said after the hearing on Thursday, July 23.

(When no one is penalized, when no final decision is made on penalizing an abusive institution, eye centers and institutions become emboldened, that it’s business as usual because it’s okay, nothing is happening, no one is penalized.)

The criticism comes as both PhilHealth and the Senate blue ribbon committee are looking into questionable claims made by several eye clinics in 2014.

In some of these clinics, patients went through cataract surgery without informed consent. Even more alarming is that some patients went through “unnecessary” laser procedures just so doctors can claim more benefits from PhilHealth.

As of July 15, 2015, 82 cases against institutions and doctors are still pending with PhilHealth’s committee on appealed administrative cases (CAAC) now chaired by former Akbayan party-list representative Risa Hontiveros.

On Thursday, Guingona pointed out that some of these cases remained pending up to 6 years. He found it alarming, too, that the CAAC held very few meetings from 2010 to 2015.

“Wala pang napaparusahan at napakatagal ng kaso diyan sa appeals court ng PhilHealth (No one has been penalized yet, and cases are lagging there in the appeals court of PhilHealth),” he added. 

Why the backlog?

The backlog is not new. In 2011, CAAC member Alexander Ayco said it bothered the committee that it was still deciding cases from the early 2000s. 

On that same year, the CAAC created a matrix that serves as a guide in penalizing health care providers and health professionals with violations.

Ayco also lamented that some members of the committee are not lawyers to begin with, so deciding on appeals takes time. But for Guingona, this does not justify PhilHealth’s backlog.

“Sinasabi nila hindi sila abugado. Meron naman silang legal department pwede magbigay ng legal advice sa kanila. Ang importante gumalaw sila….Sitting on something for 6 years is simply inexcusable,” he added.

(They say they’re not lawyers. But they have a legal department that can give them legal advice. The important thing is for them to act…. Sitting on something for 6 years is simply inexcusable.)

Reforms

Health Secretary Janette Garin said the health department will look into the issue to “cut all this bureaucracy.”

“An apology is something that is beyond our comprehension, because it is a responsibility to look out for the welfare of the other PhilHealth members,” she said during Thursday’s hearing. 

To fast-track the processing of cases, one of the proposals is to institutionalize the “stop payment” order against health care providers and professionals who are under investigation. This way, both PhilHealth and the institution/doctor will help each other to resolve the case immediately.

Currently, PhilHealth has already suspended the processing of claims of Pacific Eye Insititute-Makati and Quezon City Eye Center – two of the 10 ambulatory surgical centers with questionable PhilHealth claims for cataract procedures.

Removal of cataracts ranked 4th among the top conditions and procedures PhilHealth paid for in 2014. This is equivalent to P3.7 billion ($81.55 million)* out of the P78-billion ($1.72 billion) total benefit payments that year.

Hontiveros also said the CAAC has been implementing reforms since 2010. Hopefully, these reforms make case processing more efficient while giving due process to institutions and doctors facing cases. – Rappler.com

*US$1 = P45.37