Dubious PhilHealth claims rising, bureaucrats blamed

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Failure of the appeals committee of the Philippine Health Insurance Corporation (PhilHealth) to immediately resolve complaints involving eye centers is one of the reasons why fraudulent health claims continue to flourish, Sen. Teofisto Guingona 3rd said on Thursday.

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In the continuation of the Senate blue ribbon committee investigation of suspicious health claims made by hospitals and clinics, Guingona revealed that there are 82 cases involving various eye centers and clinics that are yet to be resolved by the Committee on Administrative Cases Against Health Care Providers and members (CAAC) of PhilHealth.
Guingona, chairman of the Senate committee, added that some of the cases have been pending for almost six years.

“How many patients have to go blind before CAAC resolves these cases?” Guingona asked committee head Riza Honteveros-Baraquel .

The senator said the delay in the resolution of cases could also be the reason why some eye centers continue to file fraudulent claims because not a single one of them has been penalized for doing so.

Dr. Alexander Ayco of CAAC admitted the delay in the resolution of cases, blaming them on absence of guidelines, causing huge case backlog, and on lack of lawyers who could have advised them on the cases.

After the hearing, the owner of the Quezon City Eye Center (QCEC) questioned PhilHealth for its decision to suspend payment of reimbursements on eye treatments made by the center.

Dr. Raymond Evangelista, CEO and president of QCEC, said PhilHealth presented inaccurate data that had been bloated by millions to support its decision.

PhilHealth earlier said QCEC in 2014 had total reimbursements of P156 million.

Evangelista said the P110 million they had received from PhilHealth included doctors’ professional fees.

He chided PhilHealth for also failing to resolve cases involving QCEC and pending before the government health insurance provider since 2010.

“We are still waiting for the CAAC’s resolution of the cases so that we can move on,” Evangelista said.

According to him, PhilHealth’s recent actions against QCEC damaged the centers reputation unnecessarily.

“We always welcome any probe of perceived mistakes and wrongdoing because we all want to stamp out corruption. We are really willing to help,” Evangelista said.

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