THIS IS in reaction to the column titled “Health is welched” (Business, 7/27/15) by Conrad Banal III. Allow us to clarify:
- On PhilHealth withholding payments for insurance claims arising from cataract operations done on PhilHealth members.
PhilHealth continues to pay valid claims for cataract procedures done on members in accredited healthcare facilities by accredited healthcare professionals. The STOP Claims (Suspension of Transactions on Payments of Claims) covers only eye clinics and doctors whose claims are under investigation. We issued this to primarily protect our members from abuse and from becoming victims of malpractices. This, however, does not hinder our members from availing themselves of their PhilHealth benefits. In fact, we have issued a public advisory reiterating that cataract surgeries remain compensable in accredited facilities anywhere in the country, for members with approved preauthorizations, qualifying contributions and updated member-data records.
- On PhilHealth suspending “future” claims and refusing to honor outstanding insurance claims of private clinics—whether or not the clinics were among those suspected of perpetuating the alleged scam.
We have not suspended any of the eye centers. In fact, the concerned eye facilities are still accredited and are supposed to continue providing the services to its clients.
- On PhilHealth’s not having the kind of money to pay for just one type of procedure to address just one kind of ailment among its 86 million-plus members.
The National Health Insurance Fund remains stable and can fully address our commitments as far as the health insurance needs of our members are concerned. Proof of our financial viability is the P78 billion we paid for our members’ claims in 2014; this year, we are averaging P1.7 billion a week in our benefit payments.
Also, aside from the reserve fund of at least P126 billion, PhilHealth was provided P35 billion more last year by the national government to cover the annual health insurance premium of indigent and senior citizen members. Hence, our fund is as solid as ever and all benefit expansions are based on actuarial studies and thorough review.
- On PhilHealth not having the infrastructure (i.e., hospitals) to honor the insurance claims of PhilHealth members.
Article VIII, Section 31 of Republic Act No. 7875, as amended by RA 10606, states: “[T]he Corporation shall have the authority to grant to health care providers accreditation which confers the privilege of participating in the Program.” Section 32 states: “All health care providers, as enumerated in
Sec. 4 (0) hereof and operating for at least three (3) years may apply for accreditation.”
Participation in the National Health Insurance Program (NHIP) is voluntary in nature, and we do process applications for accreditation, both from the government and private sectors, to further expand our network of service providers and thus enable our members to access the benefits we cover. To date, there are 5,372 healthcare facilities and 34,704 healthcare professionals that have partnered with us. As such, while claims payments for certain eye centers have been withheld, there are more than enough accredited facilities and physicians nationwide to deliver medical care services, including cataract operations, to our members.
- On PhilHealth welching on its health insurance obligations sooner or later.
Definitely, we will not renege on our commitment to our members and stakeholders. We are focused on our mandate to provide them with health insurance coverage that they can count on, especially during medical necessities, and we will continue to administer the NHIP with our members’ best interest in mind.
—ISRAEL FRANCIS A. PARGAS, MD, OIC-vice president,Corporate Affairs Group, PhilHealth, 709 Shaw Blvd., Pasig City