Philhealth admits hike in fraudulent claims


THE Philippine Health Insurance Corp. (Philhealth) on Wednesday admitted that the number of suspicious claims for benefits is growing.

Philhealth President Alex Padilla told members of Senate Blue Ribbon committee that they are looking into these suspicious claims filed by several hospitals.

“We have no real values for fraud as yet… No one really knows exactly how much money is lost to Insurance fraud yearly, only estimates can be made,” Padilla said during the Blue Ribbon investigation on the alleged scam involving some P2 billion in Philhealth funds.

Guingona called for an inquiry following the discovery of the Department of Health (DOH) on the sudden increase of claims made by several eye centers in the country.

The DOH bared that one eye center alone filed claims of close to P170 million last year, a 143 percent increase to what the clinic charged PhilHealth the previous year.

This prompted PhilHealth to stop the processing of the questionable claims pending investigation.

Based on the records of Philhealth, cataract removal ranked 4th on the insurance agency’s top conditions and procedures costing P3.7 billion in claims in 2014.

Pneumonia topped the list with P7.9 billion in claims, followed by hemodialysis, P4.6; Ceasarian delivery, P4.2 billion, and maternity care package at P1.5 billion.

“We started with eye centers because of the very conspicuous rise in claims and rising complaints from patients,” Padilla said.

The Philhealth president said they are also auditing 10 ambulatory surgical clinics and have already suspended two.

Padilla said eye centers are hiring so-called “Seekers”, “Sweepers” or “Agents” tasked to look for and entice people, preferable senior citizens, to go to eye centers for free eye cleaning treatment, not knowing that they will actually undergo surgery.

Recruiters are paid a commission ranging from P1,000 to P2,000 for each “case.” They get as much as P6,300 per cataract surgery in exchange for bringing patients.

“This payment to “seekers” eats up the P16,000 benefit for cataract (surgery) that could have gone to quality care,” the Philhealth official said.

Aside from cataract removal, the state health insurance firm has also started looking into pneumonia claims after receiving reports on the practice of “upscaling” wherein a normal cough or sore throat is “diagnosed” as pneumonia.

Padilla said Philhealth is allowed to reimburse P15,000 to P32,000 for pneumonia treatment.

They are also investigating hemodialysis claims to determine if the procedure is also being abused by unscrupulous medical institutions.

Guingona said the committee is planning to invite eye doctors who may have been involved in the questionable Philhealth claims.

He is also planning to expand the investigation and include other centers.

“But we have to wait first for the audit report being conducted by Philhealth for us to have a basis,” Guingona said.


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