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PhilHealth mess: Board explanation sought

Who should be accountable for the mess at Philippine Health Insurance Corp. (PhilHealth)?

Without pointing a finger directly at them, Sen. Panfilo Lacson said members of the PhilHealth board had a lot of explaining to do since their “defective” policies caused losses for the agency.

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Besides, Lacson said, the board also was largely in charge of fund transfers and the investigation of erring health care institutions and providers.

In a text message on Friday, Lacson said the PhilHealth board “has more explaining to do since the bleeding of their funds is largely due to defective policies, not to mention that the central office controls most of the fund transfers.”

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Moreover, he pointed out that the board, with its quasijudicial powers, was in charge of investigating erring health care institutions and providers.

Roque points to higher-ups

Harry Roque, lawyer for two whistleblowers who exposed a scheme to claim payments for “ghost” dialysis sessions, said officials higher up the ladder should be held accountable.

He said former PhilHealth chief Roy Ferrer was among those involved in allegedly questionable activities.

In a Senate hearing this week, Ferrer and former board member Roberto Salvador Jr. tagged several regional vice presidents as part of a supposed “mafia” that helped hospitals defraud the agency.

The Senate probe followed allegations that PhilHealth had been paying for bogus claims and “upscaled” cases, or illnesses that were reported to be worse than they actually were so as to charge a bigger amount in health insurance.

Roque said one issue Ferrer had to answer for was restoring the accreditation of Child Care Inc., formerly Hospital of the Infant Jesus, after it was denied by PhilHealth’s accreditation committee.

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Increase in cataract cases

He said Child Care Inc. had a questionable 365-percent increase in the number of cataract cases it had handled from 2014 to 2015.

Roque also contended that PhilHealth’s former regional vice presidents for the National Capital Region, Dennis Mas and Shirley Domingo, and present regional vice president for NCR Gilda Diaz, were among those who should be held accountable for the continued payments to Wellmed Dialysis Center despite reports of alleged fraudulent claims.

Mas also failed to act on reports of fake PhilHealth receipts used to dupe overseas Filipino workers, he added.

He also alleged that PhilHealth’s legal sector failed to act promptly on the complaints against Wellmed. He tagged senior vice president for legal Rodolfo del Rosario and senior manager of the fact-finding enforcement and investigation department Ernesto Barbado.

Overpayments

In the Inquirer’s investigative reports in June on PhilHealth fraud, insiders estimated that as much as P154 billion went to overpayments and other fraudulent schemes from 2013 to 2018.

They arrived at the amount by making computations based on the 2014 audit observation memorandum of the Commission on Audit (COA) Northern Mindanao, which found that PhilHealth overpaid in 20 percent of all cases it had processed.

International auditors

PhilHealth president Ricardo Morales told reporters on Friday that the state insurer was holding “exploratory talks” with an international auditing firm to help it fully determine the extent of the alleged fraud and the amount supposedly lost by the state insurer to corruption.

The firm, which could serve as an independent third-party auditor, has a “global reputation” for investigating medical insurance fraud, he said without identifying it.

Morales noted that the audit also was intended to ensure that the people behind the fraud would be held accountable. The audit would go “as far [back] as records are available,” he added.

“[The COA] in the years prior issued unqualified opinions. In accounting terms, that’s a seal of good housekeeping. If there’s corruption going on, how come [the] COA did not find it? Well, for one, this might not be in their mandate since they are looking at efficiency, not corruption,” he said.

‘Reckless conclusion’

Health Secretary Francisco Duque III has said that the amount lost to fraud that PhilHealth insiders estimated was a “reckless conclusion,” but he acknowledged that the fraudulent practices of some hospitals and doctors wouldn’t have prospered if there were no collusion with erring officials.

Aside from Morales, only two other new members of the board were appointed by President Duterte after the PhilHealth scam was exposed.

As of July this year, PhilHealth said it has filed 753 administrative cases against various health care providers for violating its rules and regulations. Another 921 cases are also set to be filed, while 6,138 complaints are ready for resolution by the prosecution department.

“Aside from filing cases, management is planning systemic reforms to prevent opportunities for future corruption, such as intensified identification of fraudulent providers, institutionalizing automated data analytics strategies, and strengthening and fast-tracking legal processes,” PhilHealth said in a statement on Friday.

Accomplishment records

Sen. Richard Gordon, chair of the blue ribbon committee that conducted the hearing, said he would ask PhilHealth’s regional directors to submit records of their accomplishments to see what they had done about problems in their areas.

He said he wanted to see accomplishment records of PhilHealth’s regional officials as these would show what actions they had taken to deal with the problems in their areas.

The records would show, for instance, which areas had an unusually high number of cases of pneumonia which could indicate fraudulent claims and what was done about this, he said.

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TAGS: Child Care Inc., fund transfers, Philhealth, Roy Ferrer, Sen. Panfilo Lacson
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