MANILA, Philippines — The Commission on Audit (COA) has called out Philippine Health Insurance Corp. (PhilHealth) for the surge in the number of cases and claims of members, particularly those in Metro Manila and Rizal province, for pneumonia, acute gastroenteritis, urinary tract infection, sepsis and other diseases.
In a report issued in January, the COA said these conditions were “subject to abuse” since the benefit claims were made through PhilHealth’s electronic system.
State auditors said they wanted to know if PhilHealth had really conducted “prepayment medical review” on its members afflicted with the diseases regarded as “‘red flag,’ outliers with unusual increase in volume and claims.”
The report, a copy of which was obtained by the Inquirer, confirmed the testimony of several PhilHealth insiders and other sources about “ghost” patients, overpayments and other fraudulent practices that cost the state insurance firm tens of billions of pesos.
Inquirer series
President Rodrigo Duterte fired top PhilHealth officials shortly after the Inquirer ran in June a series of reports on the fraudulent claims, overpayments and a mafia in the agency.
In a privilege speech last week, Sen. Panfilo Lacson estimated that PhilHealth lost P154 billion in overpayments and other scams perpetrated by its corrupt officials and employees over the past several years.
Lacson said these fraudulent transactions had left PhilHealth “bleeding dry,” resulting in an operating loss of P29.1 billion from 2013 to 2017.
The Senate blue ribbon committee has summoned PhilHealth officials and Health Secretary Francisco Duque III, who is also PhilHealth ex-officio chair, to a hearing about the reported irregularities.
COA, PhilHealth meeting
Last December and January, COA Commissioner Jose A. Fabia “invited” PhilHealth officials to explain the actions they had taken to deal with the irregularities.
Among the schemes the state auditors raised concern about was the prevalence of spurious PhilHealth official receipts (PORs) that recruitment agencies issued to overseas Filipino workers (OFWs) for the payment of their monthly premiums.
“Eli,” a PhilHealth employee who spoke to the Inquirer on condition of anonymity, said he had discovered that about 48 accredited placement agencies had duped more than 7,000 OFWs since 2015 by providing them with fake PORs.
Eli claimed the scheme persisted due to lack of political will and “inaction” of senior PhilHealth officials to deal with the issue.
PhilHealth spokesperson Shirley Domingo on Sunday said she was not aware of the meeting. “Neither are the concerned officers I asked regarding this,” she said.
Bogus receipts
In a memorandum, the state auditors asked Gilda Salvacion Diaz, PhilHealth vice president for Metro Manila and Rizal, if her office had made any recommendation on the complaints on the issuance of bogus PORs.
Norma Bella Portiles, the COA audit team leader for PhilHealth’s regional office in Metro Manila and Rizal, also requested copies of the documented cases of OFWs issued with fake receipts from 2015 to 2018.
Eli had earlier said the issuance of counterfeit receipts started in 2015 after the Philippine Overseas Employment Administration “strongly encouraged” migrant Filipinos to pay monthly PhilHealth contributions to its authorized collection centers and not directly to the state insurance firm.
The state audit office confirmed the existence of ghost patients, overutilization of claims and “upcasing,” which happens when a hospital charges PhilHealth, say, for pneumonia even if the patient only had common cold.
COA auditors also asked for an update on the case of a certain Ivy Rose Bongbong, a PhilHealth collecting officer at its Caloocan City office who was fired for failure to remit nearly P800,000 in PhilHealth contributions in 2011.
Kickbacks, cataracts
“In view of the foregoing, may we be informed why there was no restitution made on the unremitted collections?” the COA asked.
It also noted that “kickbacks and unnecessary cataract (operation) procedures” conducted by doctors and private health institutions had become rampant in 2015.
Since PhilHealth carried out the COA recommendations, Portiles sought the files of the “abusive eye centers” and the doctors behind the scheme.