Supreme Court: Only PhilHealth board can revoke doctor accreditations

MANILA, Philippines — The Supreme Court has ruled that the Philippine Health Insurance Corp. (PhilHealth) Board, not its president, has the authority to revoke the accreditation of healthcare professionals.

In a 20-page decision promulgated on August 19, the high court determined that PhilHealth unlawfully revoked the accreditation of Dr. Jose Mari Del Valle Galauran, an associate medical doctor at a competing dialysis center.

The case

The case stemmed from an investigation into fraudulent claims filed by WellMed Dialysis and Laboratory Center Corp. From Oct. 1 to 31, 2018, PhilHealth's Fact-Finding Investigation and Enforcement Dept. (FFIED) conducted spot inspections and claims validations in Regions IV-A, NCR, and Rizal, focusing on potential fraud in dialysis claims.

The investigation revealed that WellMed had filed claims for deceased patients and continued to charge dialysis patients out-of-pocket payments without issuing receipts. A primary case involved a fraudulent claim for a PhilHealth member who had passed away on July 16, 2016. WellMed submitted claims totaling P49,400.00 for dialysis sessions after the patient's death, with Dr. Galauran allegedly certifying the false claim.

As a result, a complaint affidavit was filed against Galauran and WellMed, charging the doctor with misrepresentation and breach of accreditation standards. Galauran denied all accusations in his response on Aug. 27, 2019, arguing that he was not liable as the patient was not his, he was not affiliated with WellMed, and he had no involvement in the fraudulent claims.

WellMed submitted claims for treatments dated after Albante’s death, with Dr. Galauran allegedly certifying the false claim that Albante had undergone dialysis after July 16.

Despite Galauran's defense, PhilHealth revoked his accreditation on August 7, 2020. Galauran appealed the decision, but it was rejected by the PhilHealth president and CEO.

Galauran then approached the Court of Appeals, which ruled in his favor, finding that the withdrawal of his accreditation was unlawful as it was made without proper authority. PhilHealth sought reconsideration, but the Court of Appeals upheld its ruling, prompting the agency to file a petition before the Supreme Court.

Supreme Court ruling

The Supreme Court affirmed the Court of Appeals' decision, stating that PhilHealth "arbitrarily and unlawfully revoked the accreditation" of Galauran and did not afford him due process.

“Consequently, the CA did not gravely abuse its discretion in setting aside the assailed orders of PhilHealth,” the court’s decision read.

The high court emphasized that under the National Health Insurance Act and its implementing rules, only the PhilHealth Board has the authority to revoke or withdraw accreditations, not the PhilHealth President.

The court also found that Galauran was denied his constitutional right to due process, as PhilHealth failed to furnish a copy of a crucial document related to the charges against him.

The Supreme Court also determined that the deceased patient's attending physician was not Galauran, and thus he did not prepare a report for the patient.

It stated, "We will not penalize healthcare professionals when there is a clear lack of evidence to support a finding of administrative liability for misrepresentation by furnishing false or incorrect information."

"We will not deprive the public of their right to health and patient care services, as well as the chance to have a better quality of life," it added.