SC stops PhilHealth payment to Pangasinan hospital for cataract operations

The Supreme Court (SC) favored the Philippine Health Insurance Corporation (PhilHealth) over the Urdaneta Sacred Heart Hospital (USHH) in the state insurer’s petition about the hospital’s reimbursement claims for cataract operations conducted from December 2008 to March 2009.

The hospital earlier filed a complaint against PhilHealth for the latter’s failure to pay or act upon the remaining 160 reimbursement claims for cataract treatments or surgeries undergone by USHH patients.

In a 13-page decision made public recently, the SC said it found in its review of the merits of the case that the USHH and its personnel had violated PhilHealth’s rules that prohibited cataract operations during medical missions.

In its petition, PhilHealth said that the USHH and several of its doctors conducted screening of patients during the period covered by the claim.

PhilHealth said that the hospital and its doctors went from one municipality in Pangasinan to another to recruit patients with cataract problems. It added that these screenings and the subsequent operations constituted medical missions since they were performed under the USHH’s Sagip Tanaw Project.

“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 the PHIC, specifically Circular Nos. 17 and 19, series of 2007,” the SC said.

Under PhilHealth Circulars No. 17 and 19, the state insurer stated that it was discontinuing the compensability of claims for cataract operations performed during medical missions and other recruitment schemes for cataract surgery, and that all claims for cataract surgeries shall not be compensated if performed during medical missions.

The SC’s decision is a reversal of the Court of Appeal’s decision on March 21, 2014, as well as a resolution dated September 17, 2014, that affirmed the ruling by the lower court directing PhilHealth to reimburse over P1.47 million in actual damages to USHH.

“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,” the SC said, adding that the COVID-19 pandemic has “stretched to its limit” the financial resources of both PhilHealth and the entire nation.

The High Court also warned healthcare institutions against abuses on claims for benefits from PhilHealth and urged medical practitioners to use the COVID-19 crisis as an opportunity to be better and craft and implement reforms in the public healthcare system.

“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,” the SC added.

Read more about the alleged syndicate-like operations involving health institutions:

• How eye clinics ‘syndicates’ defraud PhilHealth
• Eye clinics: ‘Seekers’ bring patients to doctors, not to us
• PhilHealth scam: ‘Unnecessary’ laser procedures done on patients
• PhilHealth scam: Eye doctors deny fraud allegations
• Only eye clinics in NCR monitored for fraud so far
• PhilHealth’s new limit on cataract surgeries ‘anti-poor’ – doctor
• Temporary suspension of payment claims meant to control fraud – PhilHealth

– with a report from Pauline Macaraeg/Rappler.com