State auditors: PhilHealth case rate scheme efficient but needs regular checks on claims

THE COMMISSION on Audit (CoA) said the Philippine Health Insurance Corp.’s (PhilHealth) case rate scheme, wherein values are assigned for specific treatments and medical services, was found to be efficient but prone to payment of potential false claims. In the system’s performance audit for the period 2011-2020, state auditors said while PhilHealth’s “All Case Rate Scheme” was proven efficient in terms of processing time in reimbursing claims to health care institutions, Philhealth failed to conduct regular reviews of these claims. The audit covered 67.95 million claims worth over P660 billion over the 10-year period. “If the actual costs for a treatment are significantly less than the case rate, then a corresponding adjustment in the case rate should be made. Similarly, if the actual costs are significantly higher than the case rate, then an adjustment should also be made to the case rate. This was not done, and any savings from such adjustments could have been used to augment the (PhilHealth) Reserve Fund,” CoA said. The audit agency also said PhilHealth’s existing claim review mechanisms such as the Medical Prepayment Review (MPR) was deficient in preventing inappropriate payments. From Mar. 1, 2019 to Jun. 30, 2020, a total of 878,876 claims should have undergone MPR but only 252,408 claims were reviewed. Of the remaining 626,648 claims, 443,162 claims were paid by PhilHealth despite not undergoing MPR, CoA said. Another mechanism, the Medical Post-Audit system, only checked 3.2 million claims out of the 16.48 million claims required to be post-audited from 2014 to Jun. 30, 2020. —