PhilHealth looking into ‘improbable’ claims by 3 Mindanao hospitals

UNDER INVESTIGATION One of the thousands of health institutions being probed for fraudulent Philhealth claims.—LYN RILLON

The Philippine Health Insurance Corp. (PhilHealth) on Friday said it had turned over to the National Bureau of Investigation (NBI) pieces of evidence against three Mindanao hospitals, whose alleged fraudulent schemes were far worse than those committed by WellMed Dialysis Center.

Based on data from their fraud detection mechanism, the Machine Learning Identification, Detection and Analysis System (Midas), PhilHealth officials said the amount believed to have been lost to questionable claims from these three hospitals in South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos City (Soccsksargen) run into the “tens of millions.”

While he did not identify the errant hospitals, PhilHealth legal chief Rodolfo del Rosario said the initial data they had on these health care facilities had been sent to the NBI for them “to be processed and investigated” so a stronger criminal case could be built against these institutions.

One of the alleged schemes employed by the hospitals was filing claims for a particular disease whose number exceeded the recorded incidence nationwide, Del Rosario said.

“Through Midas, we were able to determine… (that their) volume of claims was statistically improbable. There were sudden spikes in the volume of claims on specific diseases when there wasn’t a declaration of an epidemic,” he explained.

When the Inquirer published in June its investigative reports on WellMed and the fraud and corruption that gripped PhilHealth, the state insurer said that Soccsksargen accounted for a third of the nearly 9,000 hospitals and health professionals it was investigating for various violations.

To date, Del Rosario said, 4,000 of the more than 23,000 health care institutions and professionals being investigated nationwide for possible fraud are already being processed by their arbitration office, which means that prima facie evidence against them has been established.

According to PhilHealth president and chief executive officer Ricardo Morales, the sheer number of alleged fraud cases proves the need for the firm to automate “to reduce fraud.”

“We have 23,000 cases of possible fraud. Where do we start? We have six lawyers. We need investigators, fact-finders. Automation is the solution, but it will not happen overnight. That’s why there are [cases] that fall between the cracks. Our antifraud mechanism is inadequate. We need a finer net,” Morales said.

In WellMed’s case, Morales said the dialysis center ranked 800th on the list of health care institutions with alleged fraudulent claims, based on Midas data. At the time when its scheme was exposed, PhilHealth had only looked into the cases of the first 200 on the list.

Meanwhile, Del Rosario said PhilHealth has ordered the owners of WellMed to pay the agency a fine totaling some P5.2 million for the fraudulent claims it had made on top of the more than P800,000 it must return to PhilHealth for its claims for dialysis patients who had already died.

Morales said PhilHealth was considering the imposition of fines on erring hospitals instead of suspension to ensure that the agency’s efforts to curb fraud won’t compromise the welfare of patients.

Rather than withdraw the hospital’s accreditation, PhilHealth would instead suspend the processing of claims for a particular case on which fraud had been detected, while accepting claims for other services.