Duque orders review of PhilHealth IRM

MANILA, Philippines — Health Secretary Francisco Duque has ordered a review of the Interim Reimbursement Mechanism (IRM) to check for loopholes and correct possible errors in procedures.

“Confusion has arisen from the circulars issued in the haste to readily provide the needed financial support to the Health Care Institutions (HCIs) during the pandemic. Let us look into any loopholes and clarify procedures to ensure that the issues raised are responded to,” Duque said in a statement released Wednesday night.

Duque has also directed PhilHealth to come out with a systematic, clear and meritorious identification of IRM recipients so it could avoid being accused of “favoritism.”

“IRM funds should only be released upon complete submission of documents, properly vetted by the regional vice presidents,” Duque pointed out.

According to Duque, resolution of issues raised at recent congressional hearings must be rushed as prolonged suspension of the program may affect the operations of healthcare facilities.

In response to the coronavirus disease pandemic, PhilHealth issued a circular stating that “IRM shall cover PHIC claims of those affected by a fortuitous event that covers of the following, claims for treatment done as an outpatient relative to the direct and indirect effects of the fortuitous event within the HCI or in an improvised/satellite facility.”

PhilHealth said the objective of the circular is to extend help to all patients adversely affected by the pandemic such that the funds should not be made exclusive to hospitals catering to COVID-19 patients but for all HCIs caring for all patients during this pandemic.

“The effects of the pandemic, while falling heavily on COVID-19 referral facilities, have affected the entire health system. These include cancer and dialysis treatment centers, maternity clinics and other similar facilities that provide care for patients while the regular hospitals are busy addressing Covid patients. For this reason, they should also be assisted by PhilHealth,” Duque explained.

Despite the suspension of the IRM, Duque gave assurance that Filipinos can still avail themselves of all PhilHealth benefits, including ones for COVID-19 patients.

The IRM is a special prepayment mechanism allowed for healthcare institutions directly affected by “fortuitous events” and emergencies.

PhilHealth had previously made IRMs available to members during calamities like Ondoy, Yolanda, Marawi siege, and the Taal volcano eruption.

Meanwhile, Department of Justice (DOJ) Undersecretary Markk Perete said they have received inputs from PhilHealth’s senior vice president and Chief Information Officer Jovita Aragona, Corporate Secretary Jonathan Mangaoang, and acting Senior Manager for Fact-Finding Investigation and Enforcement Division (FFIED) Ernesto Barbado that could help Task Force PhilHealth in its inquiry into alleged corruption in the state insurer.

In a statement, Perete said Aragona admitted to the inability of PhilHealth’s Information and Technology (IT) systems to detect fraudulent claims.

It was earlier reported that the proposed P2.1-billion IT project, that would have been used to stop fraud and scams by some corrupt personnel, was tainted with irregularities.

Aragona said there are segments in the corporation’s validation processes that are still done manually.

She also attributed the current lack of validation mechanism in PhilHealth’s IT systems to the alleged failure of concerned offices to specify their required internal control systems during the design and development stage of the IT systems.

She also mentioned PhilHealth’s plans to develop a more sophisticated IT system.

Aragona also called for an investigation into the previously reported questionable procurement of switches by PhilHealth’s National Capital Region (NCR) office.

Mangaoang, for his part, said the controversial IRM was proposed in January to ensure that hospitals and medical establishments remain financially viable in case of emergencies and fortuitous events.

He added the PhilHealth Board approved the IRM based on an opinion issued by the corporation’s Legal Sector.

Mangaoang likewise confirmed that the board has approved the recommendation of the corporation’s Protest and Appeals Department to grant amnesty to hospitals that belatedly filed claims for reimbursement from 2011 onwards.

The law that created PhilHealth renders ineligible for reimbursement a claim filed beyond 60 days from the discharge of a patient.

Barbado, meanwhile, requested Task Force PhilHealth to look into certain ghost or fake claims previously investigated by the FFIED. — Evelyn Macairan