The Philippine Health Insurance Corp. is still investigating the cases of health care fraud involving cataract claims, Jay Villegas, head of the PhilHealth Fact- Finding and Investigative Department said in a statement issued yesterday.

He clarified, however, that the ethical issue of “ambulance chasing” by certain doctors allegedly procuring cataract patients is not within their jurisdiction, and can be addressed by their concerned medical society.

Villegas said PhilHealth can deny accreditation of health care practitioners who cannot submit certifications of good standing from the Philippine Medical Association and those who do not have recommendations from their medical societies.

Villegas explained that PhilHealth issued payments based on the ceiling provided for every case after processing good and legitimate claims.

“The investigation is still ongoing. PhilHealth only regrets that patients are unwilling to file complaints despite its efforts,” Villegas said in the statement.

He said that if the outcome of investigation warrants, the most they can do is to suspend the accreditation of these health care providers for violation of the warranties of accreditation and committing offenses against the national health insurance law and prosecute them in the proper court.

Villegas said the subject of abuse was apparently PhilHealth's previous policy of three months of premium payments within six months before availment.

But PhilHealth has issued Circular No. 36-2006 on Premium Contribution Requirement for Individually Paying Members Availing of PhilHealth Coverage for Selected Procedures, now requiring nine months of premium payments within the past 12 months before the month of confinement for procedures or services, including cataract extractions, the statement also said.*

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