COA questions on PhilHealth involve both living and dead

PhilHealth

Philippine Health Insurance Corp. (PhilHealth) may have lost at least P22.72 million last year because that amount was supposedly spent on premium payments for 4,544 elderly members who were already dead, according to a recent Commission on Audit (COA) report on the state health insurer.

The COA found that 8,156 deceased elderly PhilHealth members who should have been removed from its database were still in it.

The deaths of the 4,544, or 55.71 percent of the deceased elderly, were recorded in 2019. However, they were still included in billings to the Department of Budget and Management (DBM) for 2020, “resulting in oversubsidy from the national government amounting to P22.72 million,” the COA said.

The state auditor said PhilHealth had “deficient, weak” controls in its data collection upon learning that 0.013 percent of 6,235,438 enrolled senior citizens were already dead.

This weakness exposes the state health insurer to “risk of generating inaccurate/unreliable data and possible payment of fraudulent claims,” the COA said.

COVID-19 tests

The COA also questioned the P3.375 billion paid for COVID-19 tests using the reverse transcription-polymerase chain reaction (RT-PCR) method under PhilHealth’s interim financing mechanism (IFM).

State auditors said the disbursements do not conform with provisions for the IFM, and PhilHealth and the issuances concerning benefit packages for testing and COVID-19 case data of the Department of Health (DOH).“These disbursements could be considered unsubstantiated claims, contrary to Presidential Decree No 1445 (the Government Auditing Code),” the COA said.

It cited at least one instance where PhilHealth gave P100 million to a contactor as advance payment, which is disallowed by the code unless approved by the president.

These findings were among those contained in the report released by the state auditor last week, which said that P14.97-billion payments made under PhilHealth’s interim reimbursement mechanism (IRM) were without legal basis.

The questionable payments for the premium subsidies for the elderly and the COVID-19 tests amount to nearly P3.4 billion more from the state health insurer’s funds.

Overpayments

State auditors said the number of deceased elderly members still in the PhilHealth database and the resulting overpayments from the government could be bigger.

The audit body discovered the deficiencies after a review of the P31.177-billion billing for 2020 to the DBM covering 6,235,438 enrolled senior citizens, each with a premium of P5,000.

Only 18 responded

Under Republic Act No. 11223, or the Universal Health Care Act, the government will subsidize the PhilHealth premium of a Filipino who does not have the capacity to pay for it. This includes the enrollment of all senior citizens not covered by any other PhilHealth member category.

With the Philippine Statistics Authority reporting in May 2020 that there were 12,336,355 Filipinos age 60 and above, the DBM figures indicate that PhilHealth accounted for the premium payments of 50 percent of the country’s elderly population. The COA asked 69 PhilHealth accredited hospitals for a list of deceased patients for 2020, but only 18 responded.

This led to the discovery of 8,156 elderly PhilHealth members who were deceased but still in its database.

The COA said the figures given by the 18 hospitals represented only 1 percent of PhilHealth’s total 1,201 accredited hospitals and did not include those who died outside hospitals.

“Thus, the possibility that significant number of deceased senior citizens is not yet captured in the PhilHealth member database, given that only a percentage was considered in the team’s validation, to the prejudice of the national government that subsidizes the premium contribution,” it added.

After PhilHealth agreed with state auditors to update its database the COA found that 2,187 out of a sample of 2,344 deceased elderly members were still tagged “active instead of deceased.”

This meant that PhilHealth’s members’ status were still not updated.

State auditors could not ascertain if the information in the database was reliable, pointing out that “deficient quality of data tends to produce inaccurate reports or analyses that lead to poor decision-making.”

Under Bayanihan law

Several errors were also discovered in the encoding of data of enrolled senior citizens, such as misspelled names, wrong names encoded, errors in spacing, nonencoding of first or second names, encoding of middle initials instead of the complete middle names, errors in encoding birthdates, wrong gender entries, duplicate entries and others.

The COA said a portion of the P3.375 billion paid for 950,144 RT-PCR tests was the P100 million in advanced payment to a contractor, which was not identified in its report.

The money was paid in May 2020, a month after the contractor and PhilHealth signed a memorandum of agreement on the use of the IFM under Republic Act No. 11469, or the Bayanihan to Heal as One Act.

But the COA questioned the disbursement.

“In the absence of proof showing that the cash advance made to the contractor has legal basis or a post-facto approval of the president of the Philippines justifying exemption from the proscription against advance payment, the same was without legal authority and could be considered as illegal expenditures,” the audit body said.

It was not stated in the COA report how many of the nearly 1 billion tests was accounted for by the unidentified contractor.

State auditors added that the “propriety and occurrence of claims under the IFM amounting to P3.375 billion could not be reasonably established.”

Blank, incomplete

This was because many case information forms (CIFs) submitted for the tests contained blank fields or incomplete details, and inconsistencies and deficiencies in the validated line list or summary of test results.Payments also were made before the required CIFs were submitted, the COA said.

It said that some disbursement vouchers also did not include documents that could have determined the composition and propriety of any payment adjustments or deductions due to problems in the forms submitted, “which would indicate that claims were not thoroughly validated by PhilHealth before payment,” the COA said.

It said the release of funds for RT-PCR tests without properly accomplished CIFs was contrary to the IFM’s provisions and in PhilHealth and DOH issuances on test packages and COVID-19 data. The lack of complete CIFs also “precluded the audit team from determining the propriety of the claims.”

Revalidate payments

PhilHealth was advised to submit properly accomplished CIFs on all payments and documents supporting deductions, otherwise the disbursements would be suspended in audit. It was also told to revalidate payments to ensure that only valid tests are paid, to deduct overpayments on future claims, and to ensure that payments have complete documentation.

PhilHealth said it conducted revalidation and identified 5,374 claims with deficient records, and “adjustments amounting to P18.809 million have already been deducted from the outstanding payables to the contractor for these claims.”