Amid its renewed crackdown on fraudulent claims, the state-run Philippine Health Insurance Corp. (PhilHealth) issued a circular stipulating the guidelines on the denial, or withdrawal of accreditation, of health-care providers.
PhilHealth said in its Circular 2020-0003 that it has the authority to grant accreditation to a health-care provider, which confers the privilege of participating in the National Health Insurance Program (NHIP).
PhilHealth is also mandated to supervise the provision of health benefits and to set the standards, rules and regulations necessary to ensure access to quality health care, member satisfaction, appropriate utilization of services and fund viability.
“This policy establishes the guidelines, and procedures, on the denial and withdrawal of accreditation of health-care providers. It also enumerates the conditions that lead to the denial, or withdrawal, of accreditation, and the process involved in denial, or withdrawal, of accreditation and the remedies thereafter,” read the circular signed on February 10, 2020, by PhilHealth President and Chief Executive Officer Ricardo C. Morales.
Moreover, the policy also applies to all health-care providers both institutions and professionals that are currently participating in the NHIP, as well as to health- care providers with intention to participate in the program.
PhilHealth shall deny, or withdraw, the accreditation of health-care providers on either of the following grounds: noncompliance with any, or all, of the accreditation requirements; pending case filed with the Prosecution Department; violation of RA 7875, or the National Health Insurance Act of 2013, as amended and its revised implementing rules and regulations; and RA 11223; or the Universal Health Care Law and its implementing rules and regulations; commission of fraudulent or criminal acts prejudicial to the NHIP or other validated monitoring findings from any concerned office of the corporation.
All health-care providers with pending cases shall also be subjected to automatic review and deliberation by the PhilHealth Regional Office Accreditation Subcommittee for possible denial or withdrawal of accreditation, according to the circular.
PhilHealth shall also ensure that all health-care institutions act according to their signed Performance Commitment and shall conduct monitoring activities in line with the existing PhilHealth’s Health Care Provider Performance Assessment System.
Last year, PhilHealth revoked the accreditation of dialysis center WellMed. WellMed allegedly filed bogus claims with PhilHealth using names of dead dialysis patients.
The owner and other officers of WellMed were charged with estafa but the charges were dismissed by a Quezon City Court for having been filed in the wrong court.