PhilHealth sets new rules on pneumonia, cataract cases

The Philippine Health Insurance Corp. (PhilHealth) has rolled out new policies aimed at curbing dubious or abusive claims for pneumonia cases and cataract surgeries by hospitals, doctors and other affiliated health institutions.

To ensure that only legitimate claims will be paid out for pneumonia cases, PhilHealth president Alex Padilla said only those cases that have been confined in the hospital for at least four days or 96 hours will be compensated.

It also stopped compensating cataract surgeries performed during medical missions and through other recruitment schemes to stop fraudulent claims by eye doctors and clinics, he said.

The state insurance company started implementing the new rule for pneumonia pay-outs last September after it found out that some hospitals had been “upscaling” simple coughs and sore throats to pneumonia to be able to get higher benefit payments from PhilHealth.

“When we implemented this mid-September, the results were immediate. Within a month’s time, the claims for pneumonia cases went down by almost half so we think we are moving in the right direction,” said Padilla at a monthly press forum in Pasig City.

No. 1 in claims

Community-acquired pneumonia is the top medical condition the state insurance company paid for in the first six months of the year. Records show that there have been 283,611 claims for this disease from January to June 30, amounting to P4.066 million.

Last year, it also ranked first with P7.6 billion in total payments. The case rate for pneumonia is P15,000 for moderate-risk and P32,000 for high-risk.

PhilHealth also came out with another advisory saying cataract operations conducted during medical missions or other similar recruitment schemes would not be compensated, Padilla told reporters.

In investigating alleged fraud on claim benefits for cataract surgeries early this year, the state firm discovered that some eye centers were entering into so-called public-private partnerships with some hospitals, including government health facilities.