PhilHealth launches probe on over 15,000 'false claims' made by health facilities

Sherrie Ann Torres, ABS-CBN News

Posted at May 12 2021 08:45 PM | Updated as of May 13 2021 01:29 AM

PhilHealth launches probe on over 15,000 'false claims' made by health facilities 1
A PhilHealth local office at Mother Ignacia Street, Quezon City, taken on June 7, 2019. Mark Demayo, ABS-CBN News

MANILA (UPDATE) - More than 15,000 cases of “false claims” allegedly filed by different health facilities are now being investigated by the Philippine Health Insurance Corp.'s (PhilHealth) legal department, the agency’s spokesperson said on Wednesday.

The supposedly false claims were submitted to PhilHealth from 2019 to 2021, according to PhilHealth spokesperson Shirley Domingo, and are currently under case build-up. 

The state insurer has recorded 2,887 of such cases this year alone, she pointed out. 

Domingo said the cases could be classified as “fraudulent" and "non-fraudulent claims."

Fraudulent claims, she said, refers to the misrepresentation or giving false information, claims for non-admitting patients or the so-called ghost patients, false rating of claims, possession of fabricated forms and supporting documents, and the adding of claims and spending period of confinement. 

Non-fraudulent claims, on the other hand, are those that could be considered covering breach of warranties of accreditation, filing of multiple claims, unauthorized operation beyond service capability and unjustified admission beyond bed capacity.

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“Minsan lumalagpas sila sa bed capacity, katulad ngayon. Pero kasi may dahilan naman yun, so pwedeng hindi siya fraud,” Domingo explained.

(Sometimes they exceed the bed capacity allocation just like what happened now. There is a reason behind that, and that could not be fraudulent.)

The claims were prevalent from health facilities in Metro Manila, Calabarzon, and Central Luzon, she said. 

“As per our fact-finding department, maraming pumasok pa na cases. From the regions, kasi nagi-intensify tayo... Maraming Metro Manila only because nandito yung maraming hospitals sa NCR… sa Region 3 which is Pampanga, Bulacan, the [Region] 4A.”

(There are newly recorded cases on such matters. We intensified in the regions, but there are a lot of cases in Metro Manila because many hospitals are here. Some cases also came from Region 3 and Region 4A.) 

Pending the result of investigation, these claims will remain pending until a conclusion is reached, she said.

Domingo assured the public that PhilHealth is doing everything to speed up its investigation.

“Mayroon talaga tayong target na faster case resolution, lalo na yung mga backlog. So may target talagang tapusin agad… para ma-resolve kaagad. Na yung claims nila ma-release kaagad, or depende sa findings, made-deny yung claim."

(We have a target for faster case resolution, especially the backlogs. We have a target date when to finish it so we can resolve it immediately, so their claims will be released. But depending on the findings, there is a possibility that a claim could be denied.) 

Health facilities found guilty of fraud, she said, can either be slapped with varying penalties like fine, suspension or even revocation of accreditation if the facility has repeatedly violated the law.

HOSPITALS STRUGGLING DUE TO 'FORGOTTEN' CLAIMS

The situation complicates the already struggling status of health facilities, according to the Private Hospitals Association of the Philippines, Inc. (PHAPI). 

PHAPI's president, Dr. Jose Rene de Grano, accused the state insurer of using the false claims issue to delay the release of its obligation to hospitals. 

"Na-notice namin kasi, every time na hindi sila nakababayad sa mga hospital. 'Yan ang ginagawa nilang way of trying to intimidate the hospitals para huwag silang magreklamo,” De Grano said. 

(We noticed that happens every time they are not able to pay the hospitals. That's their way to intimidate the hospitals so they would not complain.)

“Every time, every year, for the past siguro decade na may magre-reklamo na mga hospitals, na hindi sila nababayaran, yun ang sasabihin nila - ‘O, marami kayong fraudulent claims’. To the point na ang mga hospitals natatakot din na, 'Talaga bang may ginawa kaming fraudulent?'" 

(In the past decade, every time a hospital would complain about unreleased claims, that's what PhilHealth is going to say, 'You have many fraudulent claims'. To the point that hospitals are intimidated and ask whether they really did something fraudulent.) 

At least one private hospital in the Visayas and 2 in Mindanao were allegedly forced to stop operations due to dried up funds. 

Other hospitals have already reduced their bed capacity, services and staff, he noted. 

De Grano said some hospital claims for the past years, as late as 2015 or before 2019, "amounting to billions of pesos", were already "forgotten".
 
“The truth is, gusto nilang i-cover up, yung hindi nila pagbabayad for the past year sa mga hospitals. So ngayon, pinapalabas nila na nandaraya ang mga private hospitals,” he said.

(They want to cover up the fact that they are not paying hospitals. Now, they are trying to say that private hospitals are cheating on their claims.) 

But De Grano said PHAPI does not “condone” some medical facilities' false claims if proven.

What the PHAPI is asking, he said, is due process for their members that are being accused of such violation.

“We do not go to illegal things... If they have proof, go ahead. Give our hospitals due process and then they can file the cases,” he said. 

Based on PHAPI's assessment this month, PhilHealth owes private hospitals more than P28 billion, said De Grano. 

Aside from the delayed release of claims, the group is also protesting the state insurance agency's supposed concoction of debit credit payment method (DCPM), which hospitals need to sign first. He said it is equivalent to agreeing to the release of around 35 percent of their 60 percent of claims.

What’s worse, he said, is the uncertainty of when the claims will be released. 

With many private hospitals already struggling, around 130 of 300 facilities that were offered the DCPM availed of it in order to survive.

The delay, worsened by the pandemic, has dwindled PHAPI's membership, from more than 700 pre-pandemic, to 550 at present, De Grano said.

He said the group is now contemplating on elevating their concerns before the Supreme Court aside from filing a complaint before the anti-red tape authority.

Reacting to the PHAPI's statements, PhilHealth's Domingo said they "recently met" with the group's officers to supposedly tackle issues. 

She did not elaborate, however, what issues were discussed during the meeting. 

"Hospitals are very important in this fight against COVID-19. Our communication lines are always open for them," she said. 

The state insurer in April admitted some "slowness" in reimbursing hospitals. 

PhilHealth president and CEO Dante Gierran attributed this to coronavirus infections, which he said hit some PhilHealth personnel, reduced its workforce, and prompted a lockdown of its office.

These came following allegations last year that PhilHealth officials pocketed P15 billion in public funds, approved overpriced projects, and released funds to favored hospitals amid the health crisis.

In February, Gierran said at least 94 percent of the alleged stolen funds were accounted for.