COA: PhilHealth made overpayments around P900-M in 2019

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More than ₱900 million worth of “overpayments” made by the Philippine Health Insurance Corporation to health care institutions in 2019 are uncovered by the state auditors of the Commission of Audit.

“Full reimbursements of the package rates (All Case Rates (ACR) and Z Benefit) to various Health Care Institutions (HCIs) for 312,577 sampled claims despite the lower member-patients’ actual hospital charges plus the maximum amount of Professional Fees (PF) resulted in an overpayment of ₱936.653 million,” the Commission on Audit said in a 2019 audit report for PhilHealth.

The PhilHealth’s case rate scheme provides for the fixed payment for costs for treating particular diseases regardless of how much the patient accumulates in expenses for treatment.

On the other hand, the Z benefit package aims to protect from financial risk eligible PhilHealth members with illnesses that require long hospital stays and expensive treatments.

The existing payment schemes are “detrimental to PhilHealth’s interest as the Corporation incurred unnecessary expenses,” COA pointed out.

“Moreover, the excess payments being made to the HCIs constitute a loss to PhilHealth as it could have been utilized to pay other benefit claims,” it added.

COA said the provision of overpayments violates Section 2 of Presidential Decree 1445, which states that government resources should be “safeguarded against loss or wastage through illegal or improper disposition.”

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