PhilHealth mess: CA affirms withdrawal of accreditation vs dialysis center

FILE PHOTO: Philippine Health Insurance Corp. INQUIRER FILES

MANILA, Philippines — The Court of Appeals (CA) affirmed the June 2021 decision of the Philippine Health Insurance Corporation (PhilHealth) withdrawing the accreditation of a dialysis center due to fraudulent claims for dialysis services on behalf of deceased patients.

In a decision by its eighth division promulgated on April 24, the CA said it could not find “any cogent reason to depart from the PhilHealth’s Board of Director’s ruling.”

The CA’s ruling dismisses the appeal filed by Wellmed Dialysis and Laboratory Center Corporation to reverse the June 2019 decision of PhilHealth Corp.

PhilHealth withdrew the accreditation of Wellmed after two of its former employees exposed the center’s continued claims from PhilHealth even though the patients were already dead.

PhilHealth Board said the treatment center had committed a breach of warranties due to its fraudulent claims.

But Wellmed blamed its former employees, saying they were the ones responsible for filing the fraudulent claims and claiming the money for themselves.

Aside from withdrawing its accreditation, Wellmed was ordered to pay a fine of P50,000 for being a first-time offender.

A subsequent resolution raised the fine to P100,000 in lieu of the original penalties imposed.

Wellmed then elevated the case to the PhilHealth Board, but the latter affirmed in full the decision against the dialysis center.

It then brought the case to the CA, arguing that it was not remiss in its job under the Performance Commitment with PhilHealth and that it did not breach its contract with the state-run health insurance corporation.

It explained that the non-presentation of the claim documents of the deceased patients during PhilHealth’s spot inspection was not attended by bad faith since their new employees could not locate the same due to the failure of their former employees to make a proper turnover when they resign.

But the CA said Wellmed’s explanation is “not a justifiable reason” for its violation since it is responsible for making sure that all its employees, including new ones, know their tasks.

It added that records are bereft of any indication that Wellmed exerted efforts to have a proper turnover of the documents requested by PhilHealth.

“Wellmed’s subsequent compliance to submit the requested documents is of no moment. The fact remains that it has already breached its performance commitment despite its undertaking to abide by the laws. Worse, it was also found liable for the offense of claims for non-admitted or non-treated patients,” the CA said.

The CA also dismissed Wellmed’s claims that their right to due process was violated because they had been duly informed of the allegations against them and were given ample opportunity to respond.

“These clearly show that Wellmed had been afforded the fullest opportunity to be heard and to prove its assertions. Hence, the requirement of due process was sufficiently met,” the CA added.

The Wellmed case prompted then-President Duterte to call for the resignation of PhilHealth’s officials.

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JPV