PhilHealth: ‘Overpayments’ not Fraud but ‘Efficiency Gains’

The Philippine Health Insurance Corporation (PhilHealth) explained that allegations of overpayments are untrue, reports the Philippine Daily Inquirer. Instead, these suspected overpayments are considered “efficiency gains,” according to PhilHealth spokesperson Shirley Domingo.

This clarification came after claims of fraudulent plots that supposedly cost the public insurer a whopping PHP 154 billion (USD 2.96 billion) during the past five years. Reports said that PhilHealth insurance holders were overcharged by some facilities and healthcare personnel, causing the insurer to lose its finances.

Domingo recognized the fact that some individuals with a severe variety of pneumonia made payments amounting to the all-case rate (ACT) of PHP 32,000 (USD 615.38). This applies even when facilities only require a PHP 28,000 (USD 538.45) payment. These payments were made using their public health coverage with a surplus amount of PHP 4,000 (USD 76.92).

However, Domingo also emphasized that there were cases in which the state-run insurance firm only paid the ACR even when the cost is greater than the ACR for the medical condition.

The Philippine News Agency cited PhilHealth CEO Roy Ferrer’s statement saying that ACRs “are so designed such that facilities can win some and lose some.”

According to the PNA’s report, the supposed overpayments go towards efficiency gains, a feature that the insurer has been carrying out in the past six years year. This allows the provider to implement the No Balance Billing (NBB) policy for specific cases.

Domingo also remarked that the insurance company “expect the same quality services” from medical facilities. She also said that efficiency gains enable this by balancing matters out.

Meanwhile, PhilHealth explains that its coverage includes payments for both hospital and professional charges. It is also investigating other allegations of fraud and is going after hospitals and medical professionals in question for its anti-fraud efforts.