PhilHealth ends glory days of cataract-seekers, partner docs, hospitals
An overhauling of the government's health insurance system is now in full effect that particularly addressed the controversial cataract case claims here.
With cases highest in Western Visayas region and Ilonggo doctors with most millions in claims nationwide, the Philippine Health Insurance Company (PHIC) otherwise known as PhilHealth made public the major changes.
In an advisory, PhilHealth issued implementing guidelines "to effect discontinuance of compensability of claims for cataract surgery performed during medical missions." Discontinuance too in other recruitment schemes while limiting the number of compensable claims for cataract surgery.
As per PhilHealth Circular No 19, series of 2007, medical mission or cataract missions are considered outreach programs for humanitarian and non profit purposes. As such, provided for are free cataract surgeries to people of all ages who have limited or no means to pay.
"Under the new policy, all claims including the Philippine Academy of Opthalmology (PAO) – National and Local Government Unit (LGU)- sponsored cataract surgeries, shall not be compensated if performed under the proceeding conditions," the guidelines went. "First, the health care provider, professional and/or institution, solicits patients through any means or form or through any medium that violates the Code of Ethics of PAO, that is he or she offers to or receives from a fellow physician, allied health professional or independent solicitor any fee or favor for the purpose of obtaining patients. Second, medical mission in which a health care provider has linked up with a non-government organization or an institution in the guise of charity or community service for the sole purpose of soliciting PhilHealth patients."
Soliciting of patients has since been reported as a longtime practice of a small number of eye doctors with the use of "seekers."
The News Today (TNT) in an independent investigation gathered that from P300 per eye, the seekers are now paid P600 per eye by the partner-eye doctor.
PhilHealth now wants it fully-stopped or at least not pay for the seeker's job.
"On medical mission, such is limited to PhilHealth members or beneficiaries only, or done for profit or anything that brings profit but does not promote the best interest of the patient. And, health care provider solicit patients through other recruitment schemes for the purpose of enrollment to Philhealth," the guideline continued. "However, the compensability of claims in PAO-sponsored and recognized community-based cataract surgery projects shall be subject to additional provisions in the Memorandum of Agreement between PhilHealth and PAO."
"On the other hand, National Government or Local Government Unit sponsored missions conducted in any PhilHealth accredited government facility shall be compensable subject to the provided rules as well as to the policy of pooling of professional fee," the guideline added. "PhilHealth noted further that for any indication or report of pattern indicative that such claims were done through the use of recruitment schemes, or during the conduct of medical mission, unless specified by the new Circular shall cause suspension of processing of claims pending legal investigation. Identified erring PhilHealth accredited providers shall be referred to the Committee on Ethics and Practice Management of PAO for appropriate action without prejudice to further action by the Corporation. Those found to have violated such policy shall be recommended for non-renewal or suspension or revocation of accreditation."