Cataract surgery still free in PhilHealth-accredited facilities

MANILA, Philippines - The Philippine Health Insurance Corp. (PhilHealth) assured the public yesterday that cataract surgeries remain free for its members in accredited facilities, except in eye clinics being investigated for alleged fraudulent claims.

In a statement, PhilHealth president and chief executive officer Alexander Padilla said while they withheld payment to some eye centers with dubious claims, “there are 1,826 accredited private and public facilities and over 34,000 health care professionals nationwide through which our members can avail of the benefits, including cataract operations.”

Padilla was reacting to the pronouncement of party-list group Senior Citizens that PhilHealth’s decision to withhold payments for cataract surgeries was detrimental primarily to the elderly.

“We totally disagree with the party-list group’s remarks that our unilateral decision to withhold payment to ophthalmologists and eye clinics for the alleged irregularities in performing cataract operations is tantamount to letting hundreds of thousands of Filipinos, including senior citizens, go blind,” Padilla said.

On the contrary, he said the decision to stop the processing of payments to some centers was made “to protect our members from abuse and from becoming victims of malpractices.”

PhilHealth had stopped reimbursing Pacific Eye Institute in Makati and the Quezon City Eye Center over alleged fraudulent claims amounting to hundreds of millions of pesos.

But Padilla clarified that the two eye facilities under probe are still accredited and supposed to continue providing services.

He gave assurance that the state health insurance firm’s decision to “issue the STOP Claims (Suspension of Transactions on Payments of Claims) does not hinder our members from availing themselves of their PhilHealth benefits.”

“In fact, we have issued a public advisory to our members reiterating that cataract surgeries remain to be compensable in accredited facilities anywhere in the country,” he added.

Members with approved pre-authorizations, qualifying contributions and updated member data records may avail themselves of the benefit package through case-based payment.

The package for cataract surgery, amounting to P16,000 per eye, is automatically deducted from the hospital bill after the procedure, PhilHealth said.

It added that members from the indigent and sponsored programs need not shell out a single centavo due to the implementation of the No Balance Billing policy.

Padilla stressed that PhilHealth is financially stable, noting that it has paid about P78 billion for members’ claims in 2014.

He added that this year, the agency has been paying around P1.7 billion a week, “something only a financially stable institution can do.”

Aside from a reserve fund of at least P126 billion, Padilla said PhilHealth also received P35 billion more funding this year from the national government “to cover for the health insurance premium of the country’s indigent and senior citizen members.”

“Hence, our fund is as solid as ever, and all benefit expansions are based on actuarial studies and thorough review,” he added.