The Philippine Health Insurance Corporation (PhilHealth) made overpayments of P936.653 million to health care institutions (HCIs) in 2019, the Commission on Audit (COA) said in its annual audit report.
For the same year, the state health insurer also incurred a total of P6.967 billion in unsettled audit suspensions (P84.36 million), disallowances (P6.88 billion) and charges (P2.41 million), COA also reported.
“Full reimbursement of the package rates (All Case Rates or ARC and Z Benefit) to various health care institutions for 312,577 sampled claims despite the lower member-patients’ hospital charges plus the maximum amount of professional fees resulted in overpayment of P936.653 million,” the state auditor said.
It pointed out that this deprived the people and the government of “fully achieving PhilHealth’s program objective of increasing financial health protection of member-patients since the HCIs were the ones who benefited more therefrom.”
The cases of overpayments to hospitals were noted in the National Capital Region and Rizal, CARAGA, Region 1, Region 8 and Region 9.
COA reviewed a total of 312,577 sample claims, comparing the package rate amounts of hospitals and the actual hospital charges plus profession fees.
Under the case rate system, PhilHealth pays for the entire cost of treatment package that it has fixed, even if such cost is much lower than the expenses a patient-member incurs.
The Z Benefit Package is being offered to PhilHealth members to address health conditions that trigger prolonged hospitalization and expensive treatments.
Among the illnesses covered under this package are acute lymphocytic leukemia, early breast cancer, prostate cancer, kidney transplant for end stage kidney disease, coronary artery bypass graft surgery and cervical cancer.
The report of the state audit agency came as PhilHealth undergoes an overhaul amid corruption controversies.
On Friday, more than 40 senior officers heeded the call of its new chief to step down as part of a reorganization initiative amid allegations of corruption hounding the state insurer.
Earlier, PhilHealth chief Dante Gierran issued a memo implementing a 2019 Board Resolution directing all senior officers from Salary Grade 26 and above to tender their courtesy resignation.