DOH, PhilHealth probe claims of dialysis centers

AFTER discovering questionable claims filed in 2014 by two eye centers for cataract surgeries, the Department of Health (DOH) and the state-owned Philippine Health Insurance Corp. (PhilHealth) are also looking into dialysis centers with bloated claims for possible fraud.

Health Secretary Janette Garin disclosed on Tuesday that the scope of the investigation by a task force created by the insurance firm would include dialysis centers that have registered an unusual increase in PhilHealth claims over the last two years.

“In the coming months, other cases of possible fraud will start coming in and we are looking into the possibility of checking dialysis centers,” Garin told reporters in a recent press briefing.

She revealed that an audit of the P78 billion that PhilHealth paid to affiliated healthcare institutions in 2014 also showed a suspicious spike in the coverage of hemodialysis treatment among kidney patients last year.

“The audit is still ongoing and our team has seen an increasing trend in the coverage of dialysis sessions. The intention now is to bring it down,” said Garin.

The health chief stressed the importance of government stemming fraudulent claims to allow PhilHealth to expand the coverage of dialysis sessions of kidney patients per year.

Instead of the funds going to spurious claims, PhilHealth should bankroll more dialysis sessions for its beneficiaries, she explained. “If we curb that, there is a chance for us to widen the coverage of hemodialysis treatment for our patients,” she said.

She further disclosed that PhilHealth would mark down its case rate for hemodialysis from P4,000 per session to P2,500 to be able to cover more sessions per patient from 45 to 72 sessions a year.

She added that P2,500 was enough to cover the treatment, the professional fee of the healthcare worker or doctor and the payment to the healthcare institution.

Earlier, PhilHealth president Alex Padilla announced that it has suspended the payment of claims filed by two eye centers in Metro Manila pending the results of a thorough validation of the legitimacy of their claims, particularly on cataract surgeries.

The investigation on the two eye centers was initiated after the audit of PhilHealth’s total payout to its affiliated healthcare institutions last year showed that the insurance firm paid the biggest amount for cataract operations.

Padilla had disclosed that PhilHealth was investigating roughly P2 billion worth of claims filed by affiliated hospitals and clinics for possible fraud, including P325 million worth of benefit payments issued to the two eye centers in Makati and Quezon City. SFM/ABC