Raps filed vs 12 PhilHealth, hospital officials as NBI probes COVID claims

CEBU CITY—The National Bureau of Investigation has filed graft complaints against eight officials of Philippine Health Insurance Corp. (PhilHealth) and four officers of a private hospital in Cebu City for approving an allegedly fraudulent claim for a non-COVID-19 patient.

Rennan Augustus Oliva, acting NBI director for Central Visayas (NBI-7), told the Inquirer on Friday that many other PhilHealth benefit claims for COVID-19 cases in the region were also being investigated.

“The investigation is based on the President’s order to the DOJ (Department of Justice) to create a task force to investigate PhilHealth irregularities and anomalies,” Oliva said.

Named respondents in a case filed on Thursday in the Office of the Ombudsman for the Visayas were PhilHealth Central Visayas Acting Regional Vice President Arlan Granali; Division Chief Francis Javier; Benefits Administration Section head Joan Tiu-Ayuson; Fiscal Controller Josette Bacalso; Medical Specialist Reginald Mangubat; Social Insurance Officer Anecito Ramas Jr.; Clerk III Anthonneette Maamo; and Social Insurance Assistant Kenneth Aguilar Donalvo.

Fraudulent claims

They were charged with violating Republic Act No. 3019, or the Anti-Graft and Corrupt Practices Act, malversation of public funds covered by the Revised Penal Code, violating the Code of Conduct and Ethical Standards for Public Officials and Employees, and gross and grave misconduct.

Also impleaded were four officers of Perpetual Succour Hospital (PSH) for “connivance and collusion”—Sr. Brenda Mondares, PSH finance manager; assistant department manager Gladys Sarmiento; and billing officers Jaye Anne Carcueva Aranas and Gina Misagal.

According to Oliva, NBI investigators obtained documents showing false and fraudulent claims that were approved by the PhilHealth officials in the case of a patient who died of a non-COVID-19 related pneumonia on May 16.

The patient had three negative swab tests for the new coronavirus, which causes the severe respiratory disease.

‘Upcasing’

On July 19, the hospital claimed P333,519 from PhilHealth for treating the patient under the COVID-19 severe pneumonia package, but did not include results of the swab tests.

Non-COVID-19 pneumonia should only be paid P32,000 under PhilHealth Circular No. 2020-09, the NBI said.

Oliva said that they were evaluating similar cases of fraudulent “upcasing” of PhilHealth claims in Central Visayas.

In a statement, the PhilHealth regional office welcomed the investigation, saying it had cooperated with the NBI “in every possible way such as providing them copies of claim documents and allowing them access to our warehouse for retrieval of all necessary documents.”

“It is unfortunate, however, that NBI-7 has chosen to resort to a virtual trial by publicity, as this inevitably tarnishes the integrity and reputation of the regional office and its employees, and leads to further social media backlash that does not distinguish between guilty and innocent,” the statement said.

PSH denied the charges of making fraudulent COVID-19 claims.

The nonstock, nonprofit hospital, established in 1936, is owned and managed by the nuns of St. Paul de Chartres. It has 372 beds and in March 2020, the management decided to allocate 74 for COVID-19 patients.

PSH: Claim aboveboard

In a statement on Friday, PSH lawyer Jose Ray Bael said the COVID-19 claim questioned by the NBI was “aboveboard” and based on the diagnosis of “competent and respected” medical professionals.

“The claim was supported by medical records submitted to PhilHealth and passed scrutiny and applicable criteria set by PhilHealth circulars and guidelines,” he said.

Bael said the four PSH respondents would submit a counter-affidavit to refute the allegations.

The lawyer also slammed the NBI for making a “public announcement” without giving an opportunity for the PSH personnel to answer the allegations.

The hospital had figured in another controversy, which came to light in August 2019 when lawyer Harry Roque, who had temporarily left his position as presidential spokesperson, filed graft charges against 11 former and incumbent PhilHealth executives for reaccrediting PSH after it was found guilty in 2015 of overextending the confinement period of a patient.

In his complaint affidavit filed at the Office of the Ombudsman, Roque said the decision of PhilHealth officials to overturn a Court of Appeals ruling suspending PSH allegedly cost the state health insurance company P90 million.

The PhilHealth’s own prosecution department said PSH violated the PhilHealth law and that the hospital should be suspended for three months and made to pay a P10,000 fine. PSH disputed the department ruling and sued PhilHealth in the appellate court, which upheld the legal department’s order.

Despite the appellate court’s ruling, PhilHealth’s board later took out the penalty of suspension and instead slapped a much bigger fine of P100,000.

But according to Roque, PhilHealth’s decision to reverse the suspension order cost the government at least P90 million in insurance funds or P30 million for every month that the hospital should have been suspended.