THE Supreme Court said the Board of the Philippine Health Insurance Corporation (PhilHealth), rather than its president, has the authority to revoke the accreditations of healthcare professionals.
In a decision promulgated last August 19, the SC’s First Division ruled that PhilHealth unlawfully revoked the accreditation of Dr. Jose Mari Del Valle Galauran.
The decision to revoke the accreditation of Galauran came after a fact-finding investigation by PhilHealth on medical centers in 2018 established that WellMed Dialysis and Laboratory Center filed benefit claims for the out-of-patient hospitalizations and dialysis sessions of Bebian Morte Albante amounting to P49,400 covering several dates in August and September 2016.
But records showed that Albante died on July 16, 2016.
The case alleged that Galauran certified, on behalf of WellMed, that Albante underwent dialysis sessions after July 2016.
This prompted PhilHealth’s Fact-Finding and Investigation Department to file a case against Galauran. Despite Galauran’s denial, PhilHealth still revoked his accreditation.
PhilHealth also denied his motion for reconsideration for lack of merit, prompting the latter to elevate the case to the Court of Appeals.
On September 13, 2023, the appellate court ruled in favor of Galauran, saying the authority to withdraw or revoke the accreditation is vested in PhilHealth’s Board rather than its president.
PhilHealth sought reconsideration but it proved futile as the appellate court affirmed its decision.
The state health insurance corporation then brought the case to the SC.
But the SC upheld the CA ruling and said it found no merit in PhilHealth’s arguments.
It held that the National Health Insurance Act and its implementing rules do not give the PhilHealth president the authority to revoke or withdraw an accreditation.
This power, the SC said, can only be exercised by the PhilHealth Board, and requires a majority vote from its members.
“We emphasize that the basic application for accreditation is separate and distinct from the withdrawal or revocation of accreditation. While the basic application for accreditation can be resolved by the PhilHealth President and CEO, only the PhilHealth Board, exercising its quasi-judicial power can act on the withdrawal or revocation of accreditation,” the SC ruling penned by Associate Justice Ramon Paul Hernando.
“Applied to the case at bar, the withdrawal or revocation of Dr. Galauran’s accreditation was arbitrary and without lawful authority. It is therefore a patent nullity,” it added.
The High Court also found that PhilHealth could not prove that Galauran certified the claim for non-existent dialysis treatments, adding that evidence showed that the patient’s attending physician was someone else, and Galauran did not prepare the supposed falsified report.
“PhilHealth’s documentary evidence failed to substantially establish the violations of Dr. Galauran.To recall, the documentary evidence presented by PhilHealth revealed that the deceased patient’s attending physician was a certain Dr. Natividad, not Dr. Galauran and the computer-generated report only showed Galauran’s name in the column of the list of professionals and proved that he did not prepare any report for Albante,” the SC added.
The High Court also emphasized it will not penalize healthcare providers when there is insufficient evidence.
Concurring with the decision were Chief Justice Alexander Gesmundo and Associate Justices Rodil Zalameda, Ricardo Rosario, and Jose Midas Marquez.
