PhilHealth Must Adhere to Due Process When Revoking Accreditation of Healthcare Professionals

G.R. No. 271209, August 19, 2024

Imagine a doctor, dedicated to serving patients within the PhilHealth system, suddenly finding their accreditation revoked. This can disrupt patient care and damage a professional’s reputation. This case underscores the importance of due process and the lawful authority required when PhilHealth revokes a healthcare professional’s accreditation.

In Philippine Health Insurance Corporation (PhilHealth) vs. Dr. Jose Mari Del Valle Galauran, the Supreme Court examined whether PhilHealth followed proper procedures when it withdrew Dr. Galauran’s accreditation. The Court emphasized that the PhilHealth Board, and not individual officers, holds the quasi-judicial power to revoke accreditation, and that all healthcare professionals are entitled to due process.

Understanding PhilHealth Accreditation: Legal Framework

The National Health Insurance Act (NHIA), as amended, aims to provide health services to all Filipinos, especially those who cannot afford healthcare. PhilHealth is the government corporation mandated to administer the National Health Insurance Program (NHIP). To achieve this, PhilHealth accredits healthcare providers (HCPs), including doctors, nurses, and other medical professionals. Accreditation allows these providers to participate in the NHIP.

Section 3 of the Revised Implementing Rules and Regulations (RIRR) of the NHIA defines accreditation as:

“[A] process whereby the qualifications and capabilities of health care providers are verified in accordance with the guidelines, standards, and procedures set by the Corporation for the purpose of conferring upon them the privilege of participating in the Program and assuring that health care services rendered by them are of the desired and expected quality.”

Accreditation can be initial, continuous, or involve re-accreditation. Continuous accreditation allows HCPs to participate in the program uninterrupted, until their accreditation is withdrawn based on PhilHealth’s rules. Section 75 of the RIRR vests PhilHealth with quasi-judicial powers:

“[S]ubject to the respondent’s right to due process, to suspend temporarily, revoke permanently or restore the accreditation of a health care provider… after due notice and hearing.”

However, this power resides with the PhilHealth Board, ensuring a multi-member body makes decisions affecting a professional’s accreditation. The rules also stipulate HCPs must be licensed by the Professional Regulation Commission (PRC), be members of PhilHealth, and comply with performance commitments.

The Case of Dr. Galauran: A Breakdown

Dr. Galauran, a nephrologist, was a PhilHealth-accredited HCP. PhilHealth received a report from its Fact-Finding Investigation and Enforcement Department (FFIED) that WellMed Dialysis and Laboratory Center Corporation (WellMed) filed anomalous claims for dead patients.

FFIED alleged that WellMed filed claims for Bebian Morte Albante, who had already died. PhilHealth accused Dr. Galauran of certifying that Albante underwent dialysis sessions after his death. PhilHealth then withdrew Dr. Galauran’s accreditation citing misrepresentation and breach of accreditation warranties.

Key events in the case included:

• PhilHealth ordered Dr. Galauran to answer the charges.
• Dr. Galauran denied the accusations, stating he wasn’t Albante’s doctor and didn’t sign any fraudulent claims.
• PhilHealth withdrew Dr. Galauran’s accreditation.
• Dr. Galauran appealed, but PhilHealth denied it, leading to a petition for certiorari with the Court of Appeals (CA).

The Court of Appeals reversed PhilHealth’s decision, stating that the PhilHealth Board had the authority to revoke accreditations, and that Dr. Galauran’s right to due process was violated by failing to furnish critical evidence that was used against him. The CA also noted lack of substantial evidence that Galauran committed the alleged violations. The SC agreed stating the CA did not gravely abuse its discretion.

The Supreme Court emphasized the importance of due process, quoting Quezon City Eye Center v. Philippine Health Insurance Corp.:

“The reason is that petitioner or any party similarly situated is entitled to know the case it has to meet.”

It also held that:

“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.”

Practical Implications: Protecting Healthcare Professionals

This ruling has significant implications for healthcare professionals accredited with PhilHealth. It reinforces that PhilHealth must follow proper procedures, ensuring fairness and transparency. The revocation of accreditation is a serious matter, and it must be carried out by the correct authority – the PhilHealth Board – and with full respect for due process.

Key Lessons:

• Due Process is Paramount: Healthcare professionals facing accreditation withdrawal have the right to proper notice, a fair hearing, and access to all evidence against them.
• Authority Matters: Only the PhilHealth Board has the authority to revoke accreditations.
• Substantial Evidence Required: PhilHealth must provide substantial evidence to support any decision to withdraw accreditation.

Hypothetical Example: Imagine a nurse accused of fraudulent billing. PhilHealth, without presenting concrete evidence, sends a letter revoking their accreditation. Based on the Galauran ruling, the nurse can challenge this decision, arguing that PhilHealth did not follow due process and that the action was not authorized by the PhilHealth Board.

Frequently Asked Questions

Q: What is PhilHealth accreditation?

A: It’s the process by which PhilHealth verifies the qualifications of healthcare providers, allowing them to participate in the National Health Insurance Program.

Q: Who has the authority to revoke a PhilHealth accreditation?

A: Only the PhilHealth Board, exercising its quasi-judicial powers, can revoke an accreditation.

Q: What is due process in the context of accreditation revocation?

A: It includes proper notice of the charges, a fair hearing, and access to all evidence used against the healthcare provider.

Q: What should a healthcare professional do if they believe their accreditation was unfairly revoked?

A: They should seek legal counsel and challenge the decision through proper legal channels, such as filing a petition for certiorari.

Q: What kind of evidence is required for PhilHealth to revoke accreditation?

A: PhilHealth must provide substantial evidence to support the charges against the healthcare professional.

Q: Does the PhilHealth president have the authority to withdraw accreditation?

A: No, the authority to withdraw or revoke an accreditation rests solely with the PhilHealth Board.

ASG Law specializes in healthcare law and administrative litigation. Contact us or email hello@asglawpartners.com to schedule a consultation.