CEBU, Philippines - In a continuing effort to protect the health insurance fund, PhilHealth through Circular Nos. 3, s-2010 and 47, s-2009 may now order the imposition of preventive suspension on health care providers.
The circulars, which took effect yesterday, March 9, and December 26, 2009 respectively, serve as precautionary measure to keep accredited health care providers from continuing fraudulent practices while under investigation.
Fraudulent offenses under the implementing rules and regulations of the PhilHealth law include padding of claims; claims for non-admitted patients; extending the period of confinement; postdating of claims; misrepresentation by furnishing false or incorrect information; fabrication or possession of fabricated forms and supporting documents; and other fraudulent acts or violations of the warranties of accreditation.
Preventive suspension will only be imposed on hospitals with pending administrative cases before the Arbitration Department involving fraudulent offenses where the evidence of guilt is strong, and such hospitals had been previously adjudged guilty of similar or other fraudulent offenses by PhilHealth’s Arbitration Department. Further, it may only be imposed for a period not exceeding 90 days and shall be lifted once a decision is rendered on the case or upon an order lifting the imposition of the same.
The suspension order must be imposed upon recommendation motu propio of the Arbitration Department or upon motion by the Prosecution Department, subject to the approval of the head of the Legal Services Sector.
All benefit claims filed within the suspension period will not be paid by PhilHealth unless the reason for confinement falls under emergency cases as defined by existing rules and regulations. However, such claims may be granted payment upon a motion for reconsideration filed before the concerned PhilHealth regional office and an appeal before the Protests and Appeals Review Department, where the hospital is subsequently cleared in the administrative case. -/MEEV(THE FREEMAN)