CA rejects eye doctor’s bid to void PhilHealth violation
The Court of Appeals has denied the petition of an eye doctor to overturn findings of the Philippine Health Insurance Corporation that he recruited patients in violation of Republic Act 7875 or the National Health Insurance Act.
in an 11-page decision, Associate Justice Alfonso Ruiz II of the CA Fifth Division upheld the 11 April 2019 decision of the PhilHealth board affirming the 26 October 2018 decision of the agency’s arbitration office finding Dr. Alberto Castro guilty of 17 counts of administrative offense of breach of warranties of accreditation under the NHIA.
Castro’s illegal activities were discovered after lawyer Yasser Isamel Abbas, head of the PhilHealth’s legal services unit in the National Capital Region and Rizal, conducted a regular monitoring in the Quezon City Eye Center.
After several days of investigation, Abbas found out that Castro, along with several other doctors, were recruiting patients for cataract operations.
Abbas recommended the suspension of the doctors’ claims for reimbursements with PhilHealth pending further investigation. Acting on the recommendation of Abbas, PhilHealth’s Finding Investigation and Enforcement Department conducted its own probe of the doctors.
The FFIED selected 12 patients of Castro who admitted that a free initial checkup for Philhealth members were conducted in their respective barangay.
It found that the patients were transported for free to the hospital where Castro did their eye operations.
The FFIED recommended the filing of a formal complaint against Castro and the QCEC for violation of Philhealth Circular Nos. 17 and 19 Series of 2007.
Castro denied the accusations, arguing the medical missions labeled by PhilHealth as recruitment activities were initiated by the provincial government of Bulacan.
Castro said he and several other ophthalmologists in Bulacan were invited.
All patients, whether PhilHealth members or not, were assisted during the medical missions and that he joined the free eye consultation purposely to help the less fortunate, according to Castro.
But PhilHealth found it highly questionable that patients were transported for free to and from the QCEC when the operation could have been performed in one of the government hospitals in Bulacan or in Monte Falco Hospital where the petitioner has a clinic.
Philhealth also said it has a prohibition to recruit and solicit patients who are under the programs sponsored by the Philippine Ophthalmology Association and local governments.
In upholding the decision of PhilHealth, the appellate court did not give weight to Castro’s argument that PhilHealth erred in ruling that all cataract surgeries in relation to medical missions are non-compensable as per its Circular No. 19. The circular contains the guidelines in determining whether cataract surgeries in medical mission are compensable or not.
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