P2-B PhilHealth claims under probe

The state-owned Philippine Health Insurance Corp. (PhilHealth) on Friday said it was investigating P2 billion worth of claims filed by affiliated hospitals and clinics for fraud, including P325 million worth of “highly suspicious” benefit payments issued to two eye centers in Metro Manila last year.

At a press conference yesterday, PhilHealth president Alex Padilla said at least four healthcare institutions were currently being probed by the insurance company and the Department of Health (DOH) over questionable claims that have doubled over the last two years.

Padilla said PhilHealth ordered yesterday the suspension of payments of claims filed by Pacific Eye Institute in Makati City and Quezon City Eye Center, pending the results of a thorough validation of the legitimacy of their claims, particularly for cataract surgeries.

He also disclosed that two other hospitals—one in Zamboanga Sibugay and one in Bicol—were also being investigated over questionable claims for other procedures.

In December, the insurance firm also stopped paying the claims of Corpuz Clinic and Hospital in the Ilocos Region, also over questionable claims, added Padilla.

Records showed that Pacific Eye Institute’s claims drastically jumped by 143 percent from 7,333 claims worth P69.58 million in 2013 to 11,635 claims worth P169.49 million in 2014 while the claims of Quezon City Eye Center increased from P92.5 million (9,375 claims) in 2013 to P156 million (10,944 claims) last year.

Padilla also alleged that Pacific Eye Center had a patient who lost her eyesight the day after surgery, which was supposedly done by a doctor whose license had been suspended due to unethical practices.

“The other eye center, which received more than P150 million in benefit payments, had three doctors with more than 1,000 cases of fraud filed by the eye center, no less,” added Padilla.

“We are not saying that all of these claims are fraudulent. It is possible that some of them are not but we need to study it. So for the meantime, we need to suspend payment of claims (by these centers],” Padilla told reporters.

“The jump of 143 percent in the amount being paid is in itself suspicious and necessitates an investigation,” he added.

When sought for comment, doctor David Gosiengfiao, owner of Pacific Eye Institute, denied the allegations of the health official, saying that the free cataract surgeries his clinic performed were “charity work.”

He also told reporters in an interview yesterday that one of the doctors employed by his clinic was merely suspended by the Philippine Association of Ophthalmologists but that his license to practice had not been revoked.

If fraud is established, the DOH and PhilHealth will slap criminal charges against these healthcare providers, said Padilla. “These hospitals or clinics can be suspended and their accreditation revoked,” he added.

In 2013, the DOH observed that cataract operations had become the highest paid-for service under the national health insurance program.

PhilHealth offers its members cataract surgery packages at a case rate of P16,000 each.

Health Secretary Janette Garin said random interviews with patients covered by the 2013 claims of the two eye centers indicated that some of them didn’t need cataract surgery at all.

Initial investigation on the Makati-based eye center also showed that it had a particularly high volume of patients due to a “hakot” mechanism, wherein it hired “seekers” to actively seek out PhilHealth members to operate on, some of whom did not necessarily need treatment or surgery, added Garin.

Garin said the investigations were prompted following an audit of the total P78 billion that PhilHealth paid to accredited healthcare institutions in 2014, which showed that the insurance firm paid the biggest amount for cataract operations.

“And from there, we looked at the institution or healthcare providers that had the biggest claims and those that had questionable increases in claims over the last three years even if they had not expanded their hospitals or centers,” she said.