Hit by 'ghost dialysis' scandal, PhilHealth hires fraud investigators

ABS-CBN News

Posted at Jun 06 2019 04:39 PM | Updated as of Jun 07 2019 12:07 PM

MANILA (2nd UPDATE)—PhilHealth said Thursday it will hire 130 fraud investigators following a "ghost" dialysis scandal that has rocked the government health insurance firm.

Aside from investigators, PhilHealth is also hiring 12 more lawyers, and 54 doctors to help validate claims to the agency following a report on fraudulent claims made by a dialysis center in Quezon City.

Broadsheet Philippine Daily Inquirer on Thursday reported a fraudulent claims scheme allegedly practiced by WellMed Dialysis Center in Quezon City.

The dialysis center allegedly files "ghost" claims to PhilHealth as revealed by Edwin Roberto, a former employee.

As a result, PhilHealth continues to make payments for dialysis treatments to health providers even though some of the patients have long been dead.

UNRAVELING THE SCHEME

Roberto, in an interview with reporters Thursday, said he came forward because of his conscience.

"Ako po ay lumabas na natatakot din ako para sa buhay namin. Siyempre, nakokonsensya din po kami, patay po ang na-filean ng claims sa PhilHealth," he said.

(I came forward with fear for my life. I was bothered by my conscience because claims made to PhilHealth were for dead people.)

Roberto explained that WellMed forges the signatures of its patients that die in the facility to make fraudulent claims at PhilHealth.

The scheme ran from 2016 to 2018, according to Roberto.

Explaining the process, Roberto noted that PhilHealth allows up to 90 dialysis sessions for each patient.

If a certain patient does not avail of all 90 sessions, WellMed will still file claims on behalf of the patient without his or her knowledge, he said.

"More or less 10 patients na patay na pasyente nafile-an po namin ng additional benefits. Ang ibig sabihin po noon, kahit na patay na nung 2016, file pa rin ng 2017. Continuous po siya kasi wala namang audit ang PhilHealth sa amin," he said,

(We filed additional benefits for around 10 patients that were already dead. This means that even if the patient died in 2016, we still file for claims in 2017. It's a continuous cycle because PhilHealth does not audit us.)

'NOT NEW'

Lawyer Harry Roque, who is representing Roberto, told reporters Thursday that anomalies hounding PhilHealth are nothing new.

"Dito sa Pilipinas, ang patay, hindi lang nakakaboto, nakakapag-dialysis rin," he said.

(Here in the Philippines, the dead are not just voters, they can also undergo dialysis.)

"Hindi na bago ang anomalya sa PhilHealth. Nung 16th congress
may mga pneumonia, katarata, mahihirap na hinahakot para makakolekta sa PhilHealth," he said.

(Anomalies in PhilHealth are not new. During the 16th Congress, there are poor people with pneumonia, and cataract that are being used to make claims at PhilHealth.)

Roque criticized the lack of a "checks and balance" system within the government health insurance firm to prevent corruption.

"Katunayan po ngayon, bayad lang ng bayad ang PhilHealth
lahat automated sa computer lang at isa-submit lang sa isang online service ng PhilHealth at babayaran na," he said.

(PhilHealth just makes payments because everything is automated and are just submitted online.)

"Halos wala po na kahit anong physical check na kung totoo ba na mayroon ba na beneficiaries o kung totoo ba na nagbigay ng serbisyo," he said.

(They lack a physical check system to ensure whether there are beneficiaries or whether actual service was provided.)

WellMed, however, has declined to comment on the issue.

Nurses on duty at the center told ABS-CBN News Thursday that their administration officer was not available for comment.

In a statement, WellMed's legal counsel said its client "vehemently denies the accusations" of Roberto and its former PhilHealth officer and cashier Liezel Santos.

"WellMed and its owners did not and would not, in any way, consent to, or participate in any 'ghost dialysis' or fraudulent scheme as described by Mr. Roberto," Gargantiel Ilagan and Atanante law firm said.

"Our client has filed with PhilHealth its Answer to the various complaints, and will continue to give its full cooperation in PhilHealth's investigation in order that the true perpetrators of the fraudulent scheme would be held accountable."

The firm added that WellMed will be filing criminal charges against Roberto and Santos.

"Mr. Roberto and Ms. Santos connived with each other, took advantage of the trust reposed in them by WellMed's owners, and perpetrated the fraudulent scheme, which they are now conveniently attributing to us," it said.

PHILHEALTH MAFIA?

PhilHealth President Dr. Roy Ferrer in a press conference Thursday said the agency has already filed administrative cases against WellMed and its doctors as early as last year.

"Hindi po totoo na wala kaming ginawa," Ferrer said.

(It's not true that we didn't do anything.)

PhilHealth spokesperson Shirley Domingo added that the agency has suspended issuing payments for the center.

"Ngayon we suspended the payments for this dialysis center. Tinutuloy yung investigation namin muna, pwede pa naman namin ientertain yan once we find out yung claims nila ay valid," she told radio DZMM.

(We have suspended payments for this dialysis center. Our investigation is ongoing. We will entertain claims once we find out they are valid.)

Ferrer also revealed the existence of a supposed "mafia" within PhilHealth that are contradicting the management's efforts to cleanse the agency's ranks amid reports of fraud and corruption.

Ferrer said the supposed members of this mafia have been suspended.

The agency said it is currently investigating 2,000 health providers on possible fraudulent claims. —Reports from Jeff Canoy, Kevin Manalo, and Ina Reformina, ABS-CBN News