Edwin Roberto has accused the WellMed Dialysis Center, where he used work, of filing PhilHealth claims for dialysis sessions on behalf of patients who had already died. (File photo by LYN RILLON / INQUIRER.net)
MANILA, Philippines — Health Secretary Francisco Duque III said on Tuesday that President Rodrigo Duterte has set a personal 10-day deadline to get to the bottom of the mess in the Philippine Health Insurance Corp. (PhilHealth).
In that period, Duque said that the President would look into the challenges facing PhilHealth and “mull over what he thinks might have caused the problems” in the state insurance firm.
He added that one of the solutions currently being considered now by the President to address the fraud hounding the firm would be to tap the expertise of auditor SGV&Co. “to help audit the operating and management systems of PhilHealth.”
On Monday night, the President asked for the courtesy resignation of PhilHealth’s top officials following the Philippine Daily Inquirer’s three-part investigative series on “ghost dialysis” treatments, overpayments, and other fraudulent practices, including the existence of a “mafia” behind the padded claims.
As of writing, though, no information has been released to the media as to who already sent in their resignation, which Duque said should have been given by the end of Monday.
Apart from acting president and chief executive officer Roy Ferrer, six presidential appointees are expected to turn in their resignations — Jack Arroyo Jr., Rex Maria Mendoza, Hildegardes Dineros, Celestina dela Serna, Roberto Salvador Jr., and Joan Cristine Reina Liban-Lareza.
Duque said that chief operating officer Ruben Basa would temporarily take over the firm’s operations, as ordered by the President.
He noted, though, that they were still clarifying with Malacañang whether other executives of the firm should also turn over their responsibilities to those next in line to them.
He pointed out that a reorganization was expected in the firm’s central office in the next few days as they had already identified one office that could be accountable for the ghost dialysis scheme perpetrated by Quezon City-based WellMed Dialysis Center.
“The accreditation committee is where we think there has been an oversight. That is subject to investigation,” Duque said. “We’re ordering a revamp of that particular unit, after that we’ll look at other operating units for continuing reorganization.”
Meanwhile, Duque belied the claim of PhilHealth insiders that an estimated P154 billion went to overpayments and other fraudulent practices from 2013 to 2018. PhilHealth officials earlier noted that the amount being considered as overpayments were actually “efficiency gains.”
Based on data from the firm’s Fact-Finding Investigation and Enforcement Department, he said that a total of 23,233 claims from hospitals and healthcare professionals, from 2015 to 2018, were tagged as possibly fraudulent.
At an “average value claim” of P10,000, Duque said the amount that could have been lost to fraud stands at only P232 million — or nearly just a percent of the total P433-billion benefit payout over the same period.
PhilHealth insiders came up with the amount by using the 2014 audit observation memorandum of the Commission on Audit for Northern Mindanao, which found that the firm overpaid in 20 percent of all cases it processed.
They then extrapolated the data to arrive at an overpayment amounting to P102.5. They also used the global estimate of a 10-percent loss to healthcare insurance fraud to project a P51.2-billion loss.
“An overpayment cannot be determined unless you do a hospital-to-hospital analysis or assessment. We can’t say that what is true for Northern Mindanao is also true for the entire Philippines. That is a reckless conclusion,” Duque told the Inquirer on Tuesday.
He admitted though that the fraudulent practices of some hospitals and doctors could not have prospered without collusion with erring officials.
“There is a possibility of connivance because it’s hard to believe that it is just happening without somebody from the inside who knows how to circumvent, how to go around the processes of PhilHealth,” he said. “But let’s just wait. I don’t want to preempt the outcome of the investigation.”
(Editor: Alexander T. Magno)