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  • PhilHealth Changes Rules on Pneumonia and Cataract Cases to Curb Fraud

    PhilHealth has new rules when claiming pneumonia and cataract benefits. What are they and is there an increase in contribution next year?

    December 5, 2015 | Related: ,


    PhilHealth Changes Rules on Pneumonia and Cataract Cases to Curb Fraud

    Just because you have the flu, doesn’t mean that you have pneumonia.

    And this is what PhilHealth is trying to convey to some hospitals. The Philippine Health Insurance Corporation rolled out its new policies to curb abusive claims of cataract and pneumonia cases by doctors, hospitals and other health institutions affiliated with it.

    PhilHealth is said to be seeing the positive effects of their efforts in fighting against fraud allowing it to see a decrease in a number of benefit claims for pneumonia and cataract.

    For many years now, the government agency is paying a lot of repayments for pneumonia. This makes the disease be the number 1 claim processed in the Philippines.

    96-Hour Requirement

    For that reason, PhilHealth will now require pneumonia patients to stay in the hospital for four days or 96 hours before a pneumonia payment can be claimed.

    There are several hospitals in the Philippines that committed a fraud of diagnosing their patients with high-risk pneumonia so they could ask for the R15,000 and R32,000 claims.

    Most of these patients, however, had a simple cough or asthma. They also stayed in the hospital for one day and released the next day.

    But then, these hospitals applied for pneumonia claims.

    After PhilHealth enforcing this new rule of a 96-hour hospital admission, it has seen a dramatic decline of such claims. When it was released sometime in September, the claims immediately dropped to almost half.

    Cataract Cases

    In addition to pneumonia, PhilHealth has also released new rules for claiming reimbursements on cataract operations on patients during medical missions.

    That said, the agency will no longer pay for cataract operations through a medical mission or a recruitment team.

    It was found out that some doctors and eye centers conducted cataract surgeries on patients who actually didn’t need the service.

    For every cataract operation, PhilHealth will pay R16,000 to the hospital, even if the total service fee is less than the total amount.

    PhilHealth also provides limits to doctors to only perform 10 cataract operations per day or 50 operations a month.

    The investigation about the anomaly on cataract operations is still ongoing. Currently, there were 10 facilities that received the STOP-claims from PhilHealth.

    Increase in Contributions in 2016

    On another note, PhilHealth advised its members that there will be an increase in premium contributions next year. This is in connection with the continued coverage for indigent members and senior citizens.


    About the author

    Janey Danes Janey Danes started her career as a part-time article writer, editor and proofreader in 2008. She specializes in topics related to health, travel, technology, family, and spiritual life. Danes is a licensed medical technologist and she holds a Bachelor of Science Degree in Information Technology. She is also a contributor to Travel Philippines | Entertainment and Medical Technology Avenue. You can also find her on Google+.

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