PhilHealth asks public to report ‘downcasing’

FILE PHOTO: Members line up at the counters of the Philippine Health Insurance Corporation or PhilHealth. INQUIRER FILES

MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) on Tuesday urged the public to report “downcasing” or incidents where a hospital or health facility record grave illnesses as less serious in order to minimize benefit coverage.

PhilHealth Area Vice President Walter Bacareza said their office has been receiving reports of downcasing in some hospitals and health facilities out of fear that claims would not be paid by the state insurance agency.

“Marami kaming naririnig na ganoon. Noong unang panahon ang tawag diyan upcasing, ‘yung simple ginagawang grabe. Ngayon nababago na. Downcasing naman. ‘Yung grabe ginagawang simple,” Bacareza said during the briefing of the House North Luzon Growth Quadrangle committee.

(We are receiving reports regarding that. In the beginning, it was upcasing. They are reporting less serious illnesses as grave. Now it has changed, it’s downcasing. They turn grave illnesses into simple illnesses.)

“In this case apektado ‘yung member ng Philhealth kasi instead of the hospital giving him a higher benefit, sa takot na hindi niya mabayaran…. binibigay ‘yung lower,” Bacareza added.

(In this case, the PhilHealth member is affected because instead of the hospital giving him a higher benefit, because of their fear of unpaid claims, they are slashing and giving lower benefit coverage.)

Bacareza continued: “So again we are asking every Filipino na naka-experience ng ganyan to let us know so we can file the necessary [cases] or call the attention of the facility.”

(So again we are asking every Filipino who has experienced that to let us know so we can file the necessary cases or call the attention of the facility.)

According to Philhealth Regional Vice President for Regional 1 Dennis Adre, downcasing may be treated as fraud, especially if the hospital involved “has filed a claim with a higher case rate than what was deducted from the patient.”

“The recourse is to file a case or cases against the healthcare providers for under deducting the benefits of a member and claiming a larger amount as claims by the provider,” PhilHealth Executive Vice President and Chief Operating Officer Eli Dino Santos said.

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