Philhealth reimbursements excessive in some hospitals, lawmaker reveals

RG Cruz, ABS-CBN News

Posted at Aug 18 2020 12:19 AM

MANILA - Philippine Health Insurance Corporation (PhilHealth) allocations for coronavirus patients under its interim reimbursement mechanism (IRM) exceeded the estimated cost of COVID-19 hospital admissions, a lower House lawmaker said Monday.

In her presentation to a joint committee hearing of the House Committees on Good Government, and Public Accountability and Public Accounts on the corruption allegations at the state health insurance fund, Marikina Rep. Stella Quimbo said PhilHealth estimated 209,000 COVID-19 cases for 2020. 

About 20 percent of all COVID-19 cases in the country have developed difficulty breathing and require hospital care, according to official data. Quimbo said she broke down the IRM allocations based on COVID-19 patients by case type.

According to official data, mild cases accounted for 90.3 percent of the total number of coronavirus patients in the Philippines, while severe patients were at 0.9 percent. Critical patients meanwhile were 0.6 percent of the total tally.

Quimbo said the total estimated cost for COVID-19 admissions in 2020 should be at P3.3 billion but PhilHealth set aside P26.8 billion. The lawmaker said IRM allocations/releases are based on historical claims, not on COVID-19 cases. 

According to the lawmaker, Region 1 has the 5th largest IRM, when it has only the 11th highest number of COVID cases. Region 4-B has the 9th largest IRM, when it has the 15th highest number of COVID cases. 

Region 6 meanwhile has the 5th highest number of coronavirus cases but only is 15th in IRM allocations. 

Quimbo said PhilHealth reimbursements are excessive in some hospitals, emphasizing that P1.3 million is allocated for every bed in a government hospital in Region 10, and P794,000 per bed in a private hospital in CAR, that are way more than IRM allocations in the Philippine General Hospital and the Lung Center of the Philippines, which are exclusive COVID-19 hospitals in virus-stricken Metro Manila.

Quimbo, an economist, said estimated losses due to fraud stands at P2.01405 billion while foregone income per year due to excess IRM allocations is at P541 million, for a grand total of P2.555 billion lost due to IRM designs.

During her interpellation, Quimbo got PhilHealth SVP Rene Limsiaco to admit that IRM funds can be tapped by hospital for expenses not related to COVID-19. 

“So 'yan ang talagang within the control of the hospital. Ibig sabihin, hindi lang para sa claims. Pwede nilang gamitin sa kanila operating expenses. Kaya pala tayo nagkakaproblema tayo. Halos walang control yung paggamit ng IRM. Ang alam natin kayo ay insurance fund. Hindi naman po kayo nagpapautang sa ospital. Dapat ang pinipondohan niyo lang po ay yung insurance claims,” the lawmaker said.

Upon questioning by Cavite 4th district Rep. Elpidio Barzaga, PhilHealth SVP Israel Francis Pargas confirmed the release of COVID-19 funds to hospitals is not covered by implementing rules and regulations. 

“What we have po is the guidelines. Wala pong IRR,” Pargas said.

Quimbo added: “Klarong-klaro naman po na yung IRM ay parang blank check na binigay sa mga ospital na pwedeng gamitin sa kahit ano, tsaka na lang ili-liquidate."

"Ang implication ng bulok na sistema ng IRM, na tila blank check siya at libreng pautang sa mga ospital."

Limisaco also confirmed to lawmakers that some P30 billion in special savings may be used by the PhilHealth without its board's approval. 

When Barzaga asked PhilHealth to give a position paper with the legal basis for this after they admitted that it tapped the funds for COVID-19, legal counsel Roberto Labe cited a blanket authority issued by the state insurance corporation's board in January.

“This is a blanket authority whenever there is a fortuitous event and emergencies,” he said.

The spokesperson of PhilHealth, meanwhile, said executive committee members of the state insurance corporation won’t be taking a leave of absence as the agency fights allegations of corruption.

A former anti-fraud officer of PhilHealth, in a Senate hearing this month, tagged the whole PhilHealth execom as part of an alleged mafia that purportedly stole P15 billion in public funds. 

Whistleblowers also accused them of repeatedly approving millions of pesos worth of alleged overpriced equipment and software and fund release to supposedly favored hospitals.