Hospital seeks damages from PhilHealth payment fraudsters

DAGUPAN CITY, Pangasinan, Philippines — A private hospital here filed a civil suit for damages against four people in 2015 immediately after learning that the hospital had been dragged into a racket involving fraudulent claims at Philippine Health Insurance Corp. (PhilHealth), its lawyer said on Tuesday.

In a complaint filed on April 16, 2015, at Branch 40 of the Regional Trial Court here, lawyer Aurora Valle said the modus operandi of the four people “brought so much shame and humiliation to Nazareth General Hospital” and its image as a “reputable hospital in Dagupan and Pangasinan was tainted and besmirched.”

Hospital forms used

Valle identified the four as Rosalie Zamudio, Maria Elirene Zarate, Pamela del Rosario and Corazon del Rosario.

The hospital asked for P550,000 in damages, Valle said.

According to the complaint, Zamudio, the hospital’s PhilHealth coordinator, had issued forms to Pamela del Rosario and Corazon del Rosario without the hospital’s knowledge.

The accomplished forms  were then used to collect benefits from PhilHealth using the hospital’s name.

“The receipts used did not come from Nazareth itself. There were no records that showed that Pamela and Corazon were patients of the hospital,” the complaint said.

The complaint was filed two months after a PhilHealth official announced the filing of criminal and administrative charges in the Office of the Ombudsman against two local PhilHealth employees for alleged involvement in the scheme.

Leo Douglas Cardona, who was then PhilHealth regional vice president, did not name the employees involved in the alleged irregularities. He is now PhilHealth regional vice president in Eastern Visayas.

“These are cases of fraudulent claims by at least two groups of families, perpetrated by a PhilHealth employee, in connivance with hospital staff,” he said in a press briefing in 2015.

Discovered in 2014

Cardona said the alleged irregularities were discovered in November 2014 after a PhilHealth member filed a hospitalization claim.

The member later filed for adjustment of the claim because the member apparently forgot to include the cost of medicines and computerized tomography scan.

“By the grace of our Lord and lots of luck, it was encoded in this office as a new claim instead of adjustment,” Cardona said.

He said this was immediately noticed by the standards and monitoring department of the PhilHealth central office because it appeared as “double claim.”

“So the department wrote to this office to ask them to explain why it happened. When the involved personnel here could not explain it, an antifraud team came here to look into it and the Pandora’s box was opened,” Cardona said.

He said the fraudulent claims were filed by PhilHealth employees on behalf of family members who were supposedly hospitalized.

‘Sick with cancer 5 times’

“This was not just the immediate family. This was an extended family that involved supposedly sick relatives,” Cardona said.

He said most of the claims were for cancer treatment because it was a “catastrophic illness and payments could reach up to P49,000.”

In one case, Cardona said, a member got sick with cancer five times and still lived. “The patient had primary cancer in the ovary, cervix, colon, breast, etc.,” he said.

When the National Bureau of Investigation summoned

the supposed cancer-stricken member, he was found in good health, Cardona said.

“But why and how were these checks released? And there were so many releases. There must be administrative lapses somewhere,“ he said.

Management prerogative

In November 2014, nine division chiefs and the head of the PhilHealth regional office here were reassigned to the main office of the state health insurer in Metro Manila while investigation was going on.

“This was an exercise of management prerogative to protect and secure documents and possible pieces of evidence and to minimize pilferage as the investigation was being conducted,” said Cardona, who was transferred here in November last year from the PhilHealth Central Luzon regional office before he was assigned to the Visayas office.

“These fraudulent claims involved two hospitals so far. We will be looking later into [the claims of] other hospitals,” he said. According to him, the suspected mastermind of the irregularities fled to Dubai on Nov. 3 last year, a day before PhilHealth received her resignation letter.

But Cardona said he was confident that the suspect would be repatriated to the country because the Philippines had an extradition treaty with the United Arab Emirates.

He said hold departure orders would be issued for the other suspects to prevent them from leaving the country.