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Last week, the Trade Union Congress of the
Philippines (TUCP) warned the Philippine Health Insurance Corp. (PhilHealth)
against “syndicates” that manufacture fake claims representing
reimbursements for hospitalization and medical expenses of
PhilHealth members.
Alex Aguilar, TUCP spokesman,
estimates that PhilHealth has been losing from P200 million to P400
million yearly in terms of reimbursements for “spurious”
hospitalization bills submitted for payment by “unscrupulous”
hospitals and professionals in connivance with the syndicates.
In the past 10 years, the
state-run health insurer might have lost “anywhere from P2 billion
to P4 billion” in payment of “overstated” reimbursement
claims, according to the TUCP, a federation of labor unions with the
largest coverage of the nation’s workers.
“This represents two to four
per cent of the cumulative P100 billion that PhilHealth used up for
reimbursements and administrative expenses over the same period,”
Aguilar said.
In a recent congressional
hearing, Iloilo Rep. Janette Garin, a doctor, was reported to have
named a hospital in the Visayas which had submitted a P60-million
claim representing the cost for 2,000 cataract operations on members
at P30,000 per procedure. A similar eye operation costs only P7,000.
In reaction to Garin’s
testimony, the PhilHealth acting president and chief executive
officer, Lorna Fajardo, issued a board resolution discontinuing the
compensability of claims for “cataract operations performed during
medical missions and recruitment schemes for cataract surgery”
beginning November 1.
The same resolution limits such
reimbursement claims by ascertaining they do not go beyond the
targeted volume.
The establishment of PhilHealth
in place of Medicare is a distinctive achievement of the government
in the field of social-health care. Sen. Edgardo Angara, author of
the law, considers it one of his outstanding contributions to the
Filipino people, particularly the poor.
The expansion of its coverage to
include an estimated two million senior citizens who are not covered
by the Government Service Insurance System or the Social Security
System is one of Angara’s goals.
He expects a full 100 percent
coverage of qualified citizens by 2015. He said senior citizens with
an annual income of P120,000 should be given free health insurance.
PhilHealth’s coverage goal is
80 million Filipinos in 15 years.
Millions of members look to
PhilHealth as a reliable ally in the payment of their
hospitalization expenses in the event of sickness. They pay, jointly
with their employers, monthly premiums of P100 to P750, depending on
their income.
Members are bothered by the
alarming reports of fraudulent claims paid for by the health agency.
If PhilHealth does not watch out, they warn, it may wake up one
morning to find its coffers dry. This is prejudicial to its millions
of members who may not get the appropriate medical services expected
of PhilHealth for lack of funds when a health crisis sets in.
One of their concerns is the use
of PhilHealth funds for political ends. In the recent past
elections, PhilHealth insurance cards were distributed to a big
number of people in consideration of their votes. They see the
danger of politicians dipping their fingers into its funds during
elections.
PhilHealth, like other affluent
financial institutions, keeps a rich till representing members’
monthly premiums.
The agency should keep an eye on
how much it has been losing as a result of its payment for bogus
hospitalization bills. Is it possible that some “insiders” are
in cahoots with the fake claims syndicates operating in certain
hospitals?
The TUCP has urged the Office of
the Ombudsman and the Commission on Audit to intervene “before the
problem worsens.”
Another irregularity brought to
the attention of PhilHealth is the deliberate refusal of some
hospitals to give to the proper parties “unclaimed benefits”
paid for by the agency in excess of reimbursement claims. PhilHealth
has issued a board resolution directing hospitals concerned to
return such money to members concerned within 30 days from the date
PhilHealth made the refund.
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