Abuses in collection of PhilHealth payments bared

WHAT should have been a simple sore throat or cough  has been declared a case of pneumonia, a new  modus operandi  to collect  payments from  the state-owned Philippine  Health Insurance Corp. (PhilHealth), its head  said on Wednesday.

PhilHealth president and chief executive officer Alexander Padilla said initial investigations  showed  that there were patients whose cases were “upscaled” so  that accredited hospitals or doctors  could collect payments from  PhilHealth.

“Simpleng sakit sa lalamunan ay ina up-scale nila to pneumonia para lamang makuha yung aming reimbursement na P15,000 or with complications, aabot na  P32,000 when in fact  hindi namin ito dapat binabayaran kung ito ay simpleng ubo lamang,”  he told reporters  after attending a hearing in the Senate.

“Meron isang hospital, kino-confine ang buong pamilya na nakakapagtataka. Bihira or mirakulo kung ganun na pamilya by pamilya ang nako-confine na hindi naman nangyayari yun,” he added.

During the joint hearing of the Senate’s blue ribbon and health committees, Padilla noted that payments for  PhilHealth members with  pneumonia were the  biggest in 2014 with P7.6 billion.

Next biggest payments went for hemodialysis with P4.6 billion, caesarian  delivery with P4.2 billion, removal of cataracts with P3.7 billion and  maternity care package  with  P1.5 billion.

Padilla said the  total payments  made by PhilHealth grew  by P22 billion or 28 percent from P56 billion in 2013 to P78 billion  in 2014.

During the hearing, he also detailed the alleged “fraud,” “misrepresentation,” “misinformation” and other “falsehoods”  being employed by some  eye centers  to deceive PhilHealth and its members.

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He said 26 “seekers” or recruiters  were named by patients  themselves, who allegedly enticed them to undergo  cataract operations.

“There had been reports of misinformation being propagated by certain seekers that entice PhilHealth members to undergo procedures that they are not well aware of…” said Padilla.

“Lilinisin ang mata, pakikintabin ang mata, libre naman. All these are falsehoods that lured the unsuspecting PhilHealth members  and this modus, the recruiters are paid a commission so the business of exploitation has arisen.”

Another more recently reported modus, he said, was when the “seekers” act as syndicates.

“Now, they demand kickbacks coming from the reimbursements per eye.  Apparently, this modus when employed would eat up on what otherwise would be money that should have gone to quality care of the patient,” he pointed out.

To address such abuses, Padilla said  PhilHealth  has made several recommendations such as putting a cap to the number of  patients or procedures  that an accredited doctor can reimburse  for a certain period.

Starting this Wednesday, he said PhilHealth will only reimburse payments for  10  patients or cataract operations  per doctor a day or 50 patients per doctor a month.