PhilHealth: More than P100B in losses not due to ‘overpayment’

MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) stood firm that there were no overpayments that reportedly resulted in more than P100 billion in losses.

“We really stand by our position that it’s not an overpayment, it’s efficiency gain,” PhilHealth’s Deputy Spokesperson Rey Baleña said in an interview with ABS-CBN News Channel on Monday.

“We don’t consider it as an overpayment because under the case rates regime, that’s the way we pay our providers. The case rates, wherein there are pre-determined rates already that we pay for a certain disease or illness, or treatment or procedure,” he added.

According to an Inquirer report, PhilHealth had lost a total of P154 billion since 2013. Around P102.5 billion of the said losses were due to overpayment.

READ: PhilHealth lost P154B to overpayments, fraud

Baleña explained that the case rate system promotes the efficiency of hospitals and facilities.

He said some hospitals can win and others can lose, but it means that “if they’ve been efficient with patient management with this case, then they will be receiving the fixed rate.”

“We pay P15,000 for the simple case (of pneumonia) and P32,000 for the severe case,” he said.

So if the facility is efficient and the facility was able to contain the cost and incurred only P10,000, the P5,000 that they gain from the PhilHealth payment is called the “efficiency gain.”

Baleña said the efficiency gain can be used by hospitals to improve their facilities and services.

“Prino-promote talaga ang case rate system (They promote the case rate system)…that hospitals and facilities will have to be efficient in their patient management, so if they can contain cost, then they win,” he said.

Baleña further noted that the so-called “efficiency gain” should not be a cause for alarm for hospitals and facilities.

“We encourage them to be efficient, and if they are efficient, then they get to benefit from the case rates,” he said. (Editor: Eden Estopace)