Abuses in collection of PhilHealth payments bared
WHAT should have been a simple sore throat or cough has been declared a case of pneumonia, a new modus operandi to collect payments from the state-owned Philippine Health Insurance Corp. (PhilHealth), its head said on Wednesday.
PhilHealth president and chief executive officer Alexander Padilla said initial investigations showed that there were patients whose cases were “upscaled” so that accredited hospitals or doctors could collect payments from PhilHealth.
“Simpleng sakit sa lalamunan ay ina up-scale nila to pneumonia para lamang makuha yung aming reimbursement na P15,000 or with complications, aabot na P32,000 when in fact hindi namin ito dapat binabayaran kung ito ay simpleng ubo lamang,” he told reporters after attending a hearing in the Senate.
“Meron isang hospital, kino-confine ang buong pamilya na nakakapagtataka. Bihira or mirakulo kung ganun na pamilya by pamilya ang nako-confine na hindi naman nangyayari yun,” he added.
During the joint hearing of the Senate’s blue ribbon and health committees, Padilla noted that payments for PhilHealth members with pneumonia were the biggest in 2014 with P7.6 billion.
Next biggest payments went for hemodialysis with P4.6 billion, caesarian delivery with P4.2 billion, removal of cataracts with P3.7 billion and maternity care package with P1.5 billion.
Padilla said the total payments made by PhilHealth grew by P22 billion or 28 percent from P56 billion in 2013 to P78 billion in 2014.
During the hearing, he also detailed the alleged “fraud,” “misrepresentation,” “misinformation” and other “falsehoods” being employed by some eye centers to deceive PhilHealth and its members.
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He said 26 “seekers” or recruiters were named by patients themselves, who allegedly enticed them to undergo cataract operations.
“There had been reports of misinformation being propagated by certain seekers that entice PhilHealth members to undergo procedures that they are not well aware of…” said Padilla.
“Lilinisin ang mata, pakikintabin ang mata, libre naman. All these are falsehoods that lured the unsuspecting PhilHealth members and this modus, the recruiters are paid a commission so the business of exploitation has arisen.”
Another more recently reported modus, he said, was when the “seekers” act as syndicates.
“Now, they demand kickbacks coming from the reimbursements per eye. Apparently, this modus when employed would eat up on what otherwise would be money that should have gone to quality care of the patient,” he pointed out.
To address such abuses, Padilla said PhilHealth has made several recommendations such as putting a cap to the number of patients or procedures that an accredited doctor can reimburse for a certain period.
Starting this Wednesday, he said PhilHealth will only reimburse payments for 10 patients or cataract operations per doctor a day or 50 patients per doctor a month.
