News – PH – COA: The PhilHealth program accelerated reimbursements, but there was no detection mechanism against improper payments


PhilHealth’s All Case Rate (ACR) payment scheme has improved the processing of health care facility (HCI) reimbursement claims, but has yet to work to detect and prevent improper payments, said the Commission on Audit (COA) on Wednesday 3rd March, with

In the case of the COA since the introduction of the ACR system in 2011 until 30 The performance audit conducted on June 25, 2020, improved the processing time (TAT) for processing claims from an average of 55 days during the fee for service payment scheme in 2010 to 19 days under ACR in 2019

The introduction of the electronic claims system in 2018 also contributed to a much faster TAT, emphasized COA

PhilHealth previously used the fee payment system where HCIs such as hospitals and clinics were reimbursed an amount based on the actual cost of treating the patient

However, this resulted in reimbursement delays due to differences in the rates and fees charged by individual HCIs and the difficulty of validating such fees. In some cases, this also resulted in fee bloated

Under the ACR Payment Scheme, PhilHealth pays all claims at a case rate, which is a set fixed rate for each covered case or insured illness

Instead of calculating reimbursements based on actual costs, HCI will be reimbursed a fixed amount, which may be more or less than actual costs

However, in implementing the ACR system, COA noted that PhilHealth “did not conduct the annual or even periodic review of the case as needed to determine if the case rate for a given treatment was responsive to the treatment’s actual cost”

“If the actual cost of treatment is significantly below the case rate, an adjustment to the case rate should be made. If the actual costs are significantly higher than the case rate, an adjustment to the case rate should also be made. This was not done, and Savings from such adjustments could have been used to top up the reserve fund, ”explained COA

COA also examined PhilHealth’s existing controls to prevent and detect improper payments and found that these were deficient and poor due to deficiencies in the design and implementation of controls, insufficient staffing and inadequate strategy to mitigate the impact of payments The first two problems were below average

“For example, PhilHealth set up the Medical Prepayment Review (MPR) in 2019 to monitor four diseases that are considered vulnerable to fraud March 2019 to 30 June 2020 would have a total of 878876 applications have to be subjected to an MPR, but only 252408 applications were reviewed of the remaining 626648 claims became 443162 claims paid by PhilHealth even though no MPR was performed, ”it says

“Another example is the Medical Post-Audit (MPA) mechanism that was put in place to identify improper payments after the HCI received its reimbursements from the 16 of 2014 to 30 As of June 1st, 2020, PhilHealth had 48 million claims to be re-examined, only 320 million claims were actually re-examined.The examination of these 320 million claims led to the discovery of 380413 Medical Review Results At 13 There are 54 million claims remaining for review, “he added,

To highlight the importance of the control mechanisms, PhilHealth paid P66528 billion to HCIs from 2011 to 2020, representing a reimbursement of 6795 million claims

COA recommended conducting a full case rate review to include the Case Type Z Benefit and COVID-19 packages to provide reasonable rates that minimize efficiencies and address flaws in control design and ensure controls are working effectively

It added that improper payments from citizen participation claims can be exposed and recommended that PhilHealth develop a mechanism to empower members by increasing their awareness of ACR, engagement and feedback

Philippine Health Insurance Corporation, Payment, Audit Committee

News – PH – COA: The PhilHealth system accelerated reimbursements, but lacked a detection mechanism against improper payments
Associated title :
> COA: PhilHealth system accelerated reimbursements, but there is no detection mechanism against improper payments
COA: PhilHealth&’s existing mechanisms vs. fraudulent payments poor, below average