Agency's Mandate and Functions

Mandate

The National Health Insurance Program was established to provide health insurance coverage and
ensure affordable, acceptable, available and accessible health care services for all citizens of the
Philippines. It shall serve as the means for the healthy to help pay for the care of the sick and for
those who can afford medical care to subsidize those who cannot. It shall initially consist of
Programs I and II or Medicare and be expanded progressively to constitute one universal health
insurance program for the entire population. The program shall include a sustainable system of
funds constitution, collection, management and disbursement for financing the availment of a basic
minimum package and other supplementary packages of health insurance benefits by a
progressively expanding proportion of the population. The program shall be limited to paying for the
utilization of health services by covered beneficiaries. It shall be prohibited from providing health
care directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians
and other professionals for the purpose of directly rendering care, and from owning or investing in
health care facilities. (Article III, Section 5 of RA 7875 as amended)

Powers And Functions

PhilHealth is a tax-exempt Government Corporation attached to the Department of Health for policy
coordination and guidance. (Article IV, Section 15 of RA 7875 as amended). It shall have the
following powers and functions (Article IV, Section 16 of RA 7875 as amended by RA 10606):

a) To administer the National Health Insurance Program;

b) To formulate and promulgate policies for the sound administration of the Program;

c) To supervise the provision of health benefits and to set standards, rules and regulations
necessary to ensure quality of care, appropriate utilization of services, fund viability, member
satisfaction, and overall accomplishment of Program objectives;

d) To formulate and implement guidelines on contributions and benefits; portability of benefits, cost
containment and quality assurance; and health care provider arrangements, payment, methods,
and referral systems;

e) To establish branch offices as mandated in Article V of this Act;

f) To receive and manage grants, donations, and other forms of assistance;

g) To sue and be sued in court;

h) To acquire property, real and personal, which may be necessary or expedient for the attainment
of the purposes of this Act;
i) To collect, deposit, invest, administer, and disburse the National Health Insurance Fund in
accordance with the provisions of this Act;

j) To negotiate and enter into contracts with health care institutions, professionals, and other
persons, juridical or natural, regarding the pricing, payment mechanisms, design and
implementation of administrative and operating systems and procedures, financing, and delivery of
health services in behalf of its members;

k) To authorize Local Health Insurance Offices to negotiate and enter into contracts in the name
and on behalf of the Corporation with any accredited government or private sector health provider
organization, including but not limited to health maintenance organizations, cooperatives and
medical foundations, for the provision of at least the minimum package of personal health services
prescribed by the Corporation;

l) To determine requirements and issue guidelines for the accreditation of health care providers for
the Program in accordance with this Act;

m) To visit, enter and inspect facilities of health care providers and employers during office hours,
unless there is reason to believe that inspection has to be done beyond office hours, and where
applicable, secure copies of their medical, financial, and other records and data pertinent to the
claims, accreditation, premium contribution, and that of their patients or employees, who are
members of the Program;

n) To organize its office, fix the compensation of and appoint personnel as may be deemed
necessary and upon the recommendation of the president of the Corporation;

o) To submit to the President of the Philippines and to both Houses of Congress its Annual Report
which shall contain the status of the National Health Insurance Fund, its total disbursements,
reserves, average costing to beneficiaries, any request for additional appropriation, and other data
pertinent to the implementation of the Program and publish a synopsis of such report in two (2)
newspapers of general circulation;

p) To keep records of the operations of the Corporation and investments of the National Health
Insurance Fund;

q) To establish and maintain an electronic database of all its members and ensure its security to
facilitate efficient and effective services;

r) To invest in the acceleration of the Corporation’s information technology systems;

s) To conduct information campaign on the principles of the NHIP to the public and to accredited
health care providers. This campaign must include the current benefit packages provided by the
Corporation, the mechanisms to avail of the current benefit packages, the list of accredited and
disaccredited health care providers, and the list of offices/branches where members can pay or
check the status of paid health premiums;
 t) To conduct post audit on the quality of services rendered by health care providers;

u) To establish an office, or where it is not feasible, designate a focal person in every Philippine
Consular Office in all countries where there are Filipino citizens. The office or the focal person
shall, among others, process, review and pay the claims of the overseas Filipino workers (OFWs);

v) Notwithstanding the provisions of any law to the contrary, to impose interest and/or surcharges
of not exceeding three percent (3%) per month, as may be fixed by the Corporation, in case of any
delay in the remittance of contributions which are due within the prescribed period by an employer,
whether public or private. Notwithstanding the provisions of any law to the contrary, the
Corporation may also compromise, waive or release, in whole or in part, such interest or
surcharges imposed upon employers regardless of the amount involved under such valid terms
and conditions it may prescribe;

w) To endeavour to support the use of technology in the delivery of health care services especially
in farflung areas such as, but not limited to, telemedicine, electronic health record, and the
establishment of a comprehensive health database;

x) To monitor compliance by the regulatory agencies with the requirements of this Act and to carry
out necessary actions to enforce compliance;

y) To mandate the national agencies and LGUs to require proof of PhilHealth membership before
doing business with a private individual or group;

z) To accredit independent pharmacies and retail drug outlets; and

aa) To perform such other acts as it may deem appropriate for the attainment of the objectives of
the Corporation and for the proper enforcement of the provisions of this Act.

Affiliations

 International Social Security Association

 ASEAN Social Security Association
 Philippine Social Security Association

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We are all set for UHC – PhilHealth

The government-run social health insurance agency has all the tools necessary to administer the
Universal Health Care (UHC) bill once it passes as law. Dr. Roy B. Ferrer, Acting President and
CEO of the Philippine Health Insurance Corporation (PhilHealth), confirms all systems are good to
go and that the Corporation eagerly awaits the enforcement of UHC.

“I am convinced that we have efficient processes and strict protocols in place to run the reinforced
National Health Insurance Program (NHIP),” says Ferrer and mentions that, “From the top
management to the ground level, all PhilHealth employees are apprised of their roles during this
momentous transition.”

“I am certain that our capacity to run the Program will manifest as we go along with the shift to
UHC. PhilHealth can surely manage the increase in applications for reimbursement since the law
guarantees outright benefit entitlement to all Filipinos,” Ferrer adds.

As of December 2018, PhilHealth only takes 20 days to evaluate and pay a good claim; which is 40
days faster than what the law allows. The Corporation’s efficiency proves enough to earn a 92%
net positive ratings in a satisfaction survey conducted by a private firm. In addition, PhilHealth has
been certified compliant to ISO 9001:2015 standards for implementing quality management
systems designed to meet customer requirements.

Moreover, the Corporation boasts of solid virtual frontline services to manage inquiries, feedback,
and suggestions on UHC and other NHIP matters. PhilHealth’s Corporate Action Center (CAC)
Hotline is open to serve the public from 8am-5pm, Mondays through Fridays. The hotline also
features an Interactive Voice Response System that logs callers’ voice messages after office
hours. These messages are retrieved the following business day and attended to by a live CAC
agent. Alternatively, members and stakeholders can send an e-mail at
actioncenter@philhealth.gov.ph.

PhilHealth also maintains an active presence in social media through its official Facebook, Twitter,
and YouTube accounts. “We have realized the potential of social media to augment our current
advertising and marketing campaigns,” comments Ferrer. “These [sites] improve PhilHealth’s
interaction with its members. We’ll be able to grasp what they need to know and what really
matters to them.”

The Corporation finds it imperative to toughen its anti-fraud measures and recently joined forces
with the National Bureau of Investigation (NBI), Philippine Medical Association (PMA), Philippine
Hospital Association (PHA), and Professional Regulation Commission (PRC) to tighten the noose
of justice around the necks of fraudulent health care professionals and hospitals. Memoranda of
Agreement are signed to formalize the collaboration.

During the deliberations of the 2019 budget, Senate President Vicente Sotto III exposed a certain
neurologist from South Cotabato who uses “recruiters” to hire PhilHealth members and file for
bogus reimbursements.

“I will not allow these fraudulent entities to undermine our noble intentions. Not now, not ever,” says
the PhilHealth chief. “The people only deserve an honest and morally-upright institution to run their
Program. Such conduct has no place in UHC.”

The enactment of the UHC bill marks the completion of PhilHealth’s journey – attainment of the
mythical 100%-coverage mark. “In the following years after the law’s enactment, everyone who
supported its [UHC] fulfillment can take pride for their contribution in improving our health care
system. What a great success story it would be for future generations,” Ferrer reflects. END (JJ
Rico)

THE GHOSTS OF PHILHEALTH

Until very recently, things were somewhat looking good for the health care sector. The fallout from
the Dengvaxia scandal still lingers, but its effect on vaccination confidence seem to have been
neutralized — ironically — by the measles outbreak.

Capping off a series of health-related legislation passed over the past two years, the universal
health care (UHC) law was also approved in February, and the much-needed revision of the sin tax
law, though delayed, seems to have made it — by a hair — before the end of the 17th Congress.

This euphoria, however, was dampened when news broke of a private clinic in Novaliches that was
said to have made dialysis claims for patients who were already dead. Drawing on the testimony of
two whistleblowers who worked at WellMed Dialysis Center, a three-part exposé in this broadsheet
went on to document other kinds of insurance fraud (e.g. “upcasing”), their financial toll (P154
billion no less), and the complicity of a Philippine Health Insurance Corp. (PhilHealth) “mafia” in
perpetuating corruption in the state insurance company.

“It’s very disappointing, knowing that so many of us are doing our best to follow the strict
requirements of PhilHealth [to make claims], and we have so many patients who are trying to make
do with their maximum of 90 dialysis sessions a year,” a nephrologist who requested anonymity
told me in response to the news.

President Duterte was quick to express fury over the situation, ordering the arrest of the clinic
owners and a purge of the PhilHealth leadership. Back from political hibernation, Harry Roque has
surfaced as the lawyer for the whistleblowers, and is calling for the suspension of the UHC law until
the issue is resolved, citing the “corrupt pigs” in PhilHealth.
I do not think the UHC law should be suspended; we cannot allow a corruption scandal to deprive
legitimate patients of health care. But Roque has a point: How can we expect the people and the
government to go along with our call to invest more on health if the funds end up being stolen? The
PhilHealth scandal raises the question of trust, which is why it must be taken very seriously.

How can we move forward from this fiasco?

The first is by exacting justice — one that is not abusive, selective or reactionary. The swift arrest
of Dr. Brian Sy, WellMed owner, may be cheered by many, but its warrantless nature raises the
question of adherence to the rule of law, which cannot be sacrificed in the name of “justice.”
Moreover, if there is indeed a mafia in PhilHealth, the alleged malpractice in WellMed is just the tip
of the iceberg.
Of the hospitals and officials involved in insurance fraud, which ones get to be investigated and
who gets a free pass? How many will actually have their licenses revoked? As with the
administration’s campaigns against drugs and corruption, vigorously pursuing cases against some
while turning a blind eye to others will undermine the credibility of the entire campaign and will not
solve the problem of mistrust.

The second is by ensuring competent leadership in PhilHealth. With so much money in the
agency’s hands, we need people with integrity and innovation at its helm. I urge President Duterte
to think carefully, and be as consultative as possible, in deciding who to appoint (or retain) in the
PhilHealth board. Health is too important to be handed over to an unqualified presidential friend—
or an owner of a hospital group. Conflicts of interest should be avoided at all costs.

The third is by improving PhilHealth’s patient database. “This scandal has exposed their loophole
— they actually have no means to check if the patient is dead or alive!” exclaimed the nephrologist
I spoke to, underscoring the need for a more effective and responsive health information system.

ADVERTISEMENT
If there’s any silver lining in this situation, it is the opportunity to make meaningful, structural and
sustainable reforms in PhilHealth — which, in the wake of this scandal, can have the popular
support and political backing required to exorcise its ghosts and banish the spirit of greed. Given
what’s at stake — public trust in our health care system—this is an opportunity that we must take at
all costs. The legitimacy of PhilHealth and the viability of the UHC depend on it.

Read more: https://opinion.inquirer.net/121942/the-ghosts-of-philhealth#ixzz5zSw52mXB

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PhilHealth mess magnifies 'pervasive' corruption in gov't: PRRD

MANILA -- President Rodrigo Duterte on Monday stressed the prevalence of corruption in the
country by citing the ghost claims that hounded the Philippine Health Insurance Corporation
(PhilHealth) in the past months.

"The recent uncovering of the massive fraud that perpetrated against the public health insurance
proved that corruption is pervasive. (A) Huge amount of medical funds were released to ghost
claims and imaginary treatment of ghost payments. I am grossly disappointed," Duterte said in his
fourth State of the Nation Address (SONA).
In June, the PhilHealth's reputation was marred by ghost medical claims filed on behalf of
deceased dialysis patients of WellMed Dialysis Center.
To solve the issue, Duterte has instructed the National Bureau of Investigation to arrest the
perpetrators.

"The government is robbed of millions of pesos which could be used to treat illnesses and possibly
save the lives of many. I appointed a new PhilHealth president, whom I know is a man of integrity
and military man, a former military officer," he said.

Duterte added that he has given PhilHealth head Ricardo Morales "marching orders to prioritize
weeding the agency of corruption". (PNA)
Duterte asks PhilHealth execs to resign amid fraud scandal, says Bong Go

ABS-CBN News

Posted at Jun 10 2019 04:18 PM | Updated as of Jun 10 2019 11:06 PM

PhilHealth temporarily placed under Office of the President

MANILA (2nd UPDATE) - President Rodrigo Duterte has asked officials of the Philippine Health
Insurance Corporation (PhilHealth) to resign amid reports of fraudulent claims.
Senator-elect Christopher "Bong" Go, who is set to head the Senate’s health committee in the
upcoming 18th Congress, said Duterte relayed the instruction to PhilHealth officials through him.

Go said the PhilHealth officials were scheduled to submit their courtesy resignation to Duterte in a
meeting scheduled at 5:30 p.m. Monday.

In a statement released after said meeting, Go said Duterte was disappointed with the corruption
allegations, and wanted a "clean slate" for PhilHealth.

He added Duterte has also asked the National Bureau of Investigation (NBI) to investigate the
incident.

"Gusto ni Pangulo ng clean slate sa pamunuan ng PhilHealth. Kailangan rin maklaro kung paano
nakalusot ng napakatagal na panahon ang ganitong anomalya ng fraudulent claims sa
pamamalakad ng kasalukuyang mga opisyal. Inutusan ng Pangulo ang NBI na imbestigahan ito sa
mabilisang panahon," Go said.

(The President wants a clean slate in the PhilHealth administration. It should also be clear how the
fraudulent claims went on for a long time under the administration of current officials. The President
has asked the NBI to investigate the incident as soon as possible.)
"Sa ngayon, plantilla officials muna ang temporary na mamamalakad at maa-assign sila under the
Office of the President," he added.
(For now, plantilla officials will temporarily run the agency, which will be placed under the
jurisdiction of the Office of the President.)

Duterte appointed PhilHealth President Roy Ferrer last year after letting go of Celestina Ma. Jude
Dela Serna, who got embroiled in a controversy over her supposedly excessive expenses on trips
and hotel accommodations.

Go added that Duterte is also considering a nationwide revamp of PhilHealth. He said the
President might also fire regional officials.

Meanwhile, the Palace said operations in the government health agency would continue amid the
scandal.

"There is zero tolerance on corruption under this Administration. There will be an in-depth study on
how the frauds are systematically committed by unscrupulous persons in and out of PhilHealth.
There will be criminal prosecutions of all those involved. No one will be spared," Presidential
Spokesperson Salvador Panelo said in a statement.

Last week, broadsheet Philippine Daily Inquirer reported that WellMed Clinic filed "ghost" claims to
PhilHealth as revealed by Edwin Roberto, a former employee.

Under the scheme, the clinic received payments from PhilHealth for dialysis treatments even
though some of the patients have long been dead.

Dr. Brian Sy, owner of the WellMed Dialysis Center in Quezon City, explained to the NBI that
former employees of the clinic were the ones supposedly involved in fraudulent claims.
The scandal involved bogus insurance claims allegedly amounting to more than P100 billion.
Duterte to 'reorganize' Philhealth after P154-billion loss to 'ghost' patients, deliveries
The President earlier noted that he does "not have the slightest doubt about the integrity and
honesty" of Ferrer, but that a loss of around P100 billion is "totally, totally unacceptable."
ABS-CBN News has reached out to PhilHealth for comment but the agency has yet to respond.
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PhilHealth decries ‘slanted report’ on fake receipts, denies conflict of interest in Dagupan
building lease

THE Philippine Health Insurance Corp. (PhilHealth) protested on Friday what it called the “slanted
report” about the fake PhilHealth Official Receipts (PORs) issued by liaison officers of recruitment
agencies to a number of OFW members supposedly for their premium contributions.

The report came out in the Philippine Daily Inquirer.

PhilHealth said it had acted promptly on the issue in order to penalize those who are guilty in
particular; and protect the National Health Insurance Fund in general.

“There were considerable efforts exerted by PhilHealth in response to this duplicity. Mr. Dennis S.
Mas, then Regional Vice-President for NCR and now Senior Vice President for Management
Services, spearheaded calls for investigation to uncover the modus. His endorsement proved
crucial to the current undertakings of PhilHealth against these forged receipts. In November 2015,
then PhilHealth President and CEO Alexander Padilla requested the National Bureau of
Investigation to conduct an inquiry pertaining to the falsified PORs,” the state health insurer said in
a statement sent to media.

PhilHealth also sought to “clarify that the issued fake receipts amounted only to P1.2 million,
contrary to the report which stated at least P17.4 million. Moreover, PhilHealth maintained that no
funds were lost over this modus.”

Of late, it said, a total of P208,800 have been collected already from the identified recruitment
agencies where the spurious transactions emanated. PhilHealth said it is awaiting settlement from
the other recruitment agencies; sent final demand letters; and endorsed some of the cases to the
Legal Services Unit of the PhilHealth-NCR for appropriate action.

“Finally, there was no evidence involving any of PhilHealth personnel to this fraudulent activity. The
falsification was initiated by the unscrupulous liaison officers themselves who were said to connive
with a certain personality at the Philippine Overseas Employment Agency (POEA) in order to
commit fraud,” according to PhilHealth.

Dagupan office lease

Meanwhile, PhilHealth insisted there is no conflict of interest in the lease contract for office space
of PhilHealth Regional Office I in Dagupan City with the Educational and Medical Development
Corporation (EDMC), owned by the family of Health Secretary Francisco Duque III. PhilHealth
noted that “the decision-making in procurement implementation rests solely with the PhilHealth
management and does not pass through the PhilHealth Board of Directors.”
Moreover, PhilHealth said the “procurement was in accordance with the process and procedures
set by the Government Procurement Reform Act or RA 9184.”

The alleged conflict of interest was flagged by Sen. Panfilo Lacson last week.
In its statement on Friday PhilHealth said that although it “is besieged by issues that have either
been long resolved, or have been endorsed to the proper government agencies, we continue to
relentlessly fulfill our fiduciary duty to protect the national health insurance funds and serve the
Filipinos.”
PhilHealth must fix its problems ASAP

I’m always interested in any news that talks about kidneys, after all, I had a kidney transplant two
years ago. Then we read that disturbing news that Philippine Health Insurance Corp. (PhilHealth)
filed administrative cases against WellMed Dialysis and Laboratory Center in Novaliches, Quezon
City last November for misrepresentation and falsification where it was revealed that PhilHealth
continued paying for the dialysis treatments of a patient who had died in 2016 after the dialysis
center continued filing claims for the “ghost” sessions. It was indeed a disturbing report.

This is why we were glad that no less than President Rodrigo Duterte last Saturday ordered the
National Bureau of Investigation (NBI) to arrest and probe the owners of a dialysis facility in
Quezon City that allegedly made bogus benefit claims for non-existent kidney treatments.
PhilHealth apparently said that there is a move to withdraw the accreditation of the center. It added
that payment for all claims filed by the dialysis facility had been suspended as early as of February
this year.

Pres. Duterte also directed the PhilHealth management to pursue criminal charges against those
officials and employees who allowed, wittingly or unwittingly, such misuse of funds to take place for
years and instructed PhilHealth to submit a detailed report on the irregularities. While PhilHealth
has already taken action on the matter, Presidential spokesman Salvador Panelo said Duterte
wants charges to be pursued against the erring officials. Surely by now PhilHealth employees or
the so-called “mafia” inside know that Pres. Duterte abhors corrupt government employees and is
determined to weed out government offices of corruption.

Mind you, in fairness to PhilHealth in Region 7, I was given financial support by this agency two
years ago when I had my kidney transplant operation at the Vicente Sotto Medical Center (VSMC).
I would not have been given such assistance if I had my kidney transplant in a private hospital. It
turned out to be a good thing in the sense that I kept writing on my columns about my medical
condition so my readers would know more about issues related to kidneys. In the end, the articles I
wrote about my kidney transplant became a very important link to many readers who were having
kidney problems. So many people need PhilHealth for their dialysis treatments.

Meanwhile, we learned that Health Secretary Francisco Duque III has warned all healthcare
facilities and health professionals accredited with PhilHealth that they would lose their accreditation
if they make fraudulent claims. Sec. Duque said that erring facilities and professionals “stand to
lose much” if they engage in nefarious activities, like padding their claims or seeking
reimbursement for services they did not render. This should be a warning to all that they should
stop these irregularities, which is a criminal act. Incidentally, the Health Secretary assured the
public that there are reforms being instituted to protect PhilHealth funds “but the outcomes of these
reforms will not be felt immediately.”

Still on the same issue, PhilHealth president Roy Ferrer said that at least 28 counts of
misrepresentation and falsification were filed against WellMed Dialysis and Laboratory Center
Corp. before the courts. PhilHealth also filed cases against doctors who were possibly involved in
such anomaly that occurred since 2016. Ferrer added that “under its present leadership, PhilHealth
would not let thievery, in any form, to prosper. Not on my watch.” At this point, we can only hope
that PhilHealth would finally put a stop to all shenanigans within their organization and emphasize
to PhilHealth employees that fighting corruption is the pet peeve of no less than Pres. Rodrigo
Duterte.

***

Last Saturday, I attended the thanksgiving dinner hosted by Office of the Presidential Assistant for
the Visayas (OPAV) Michael Lloyd Dino for Senator-Elect Bong Go at the Oakridge Executive Club
and Business Park in Mandaue City. It was the first time for me to meet the winners of the May 13
election since I was on my three-week vacation to Europe. Of course, when he arrived, I had a
selfie with Sen. Elect Bong Go and held a photo session with many winners of that mid-term
elections.

By the way, it was also the birthday of Sen. Elect Bong Go and Michael Dino and his staff prepared
a birthday cake for him. But speaking in Cebuano, the senator-elect asked that this was a night for
him to thank all who supported him and Pres Duterte. But he refused to call it his birthday party
because he said, he followed the style of Pres. Duterte who spends his birthday quietly with his
family. Indeed, his winning his senatorial bid has not gotten into his head and he went around the
Executive Club talking and taking photos with as many people as he could.

***

Email: vsbobita@gmail.com
Read more at https://www.philstar.com/opinion/2019/06/11/1925555/philhealth-must-fix-its-
problems-asap#MiChWcXr3022iZTH.99
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