In a country where many citizens are unable to afford the services of doctors and/or hospitals, it is unconscionable to learn that funds of the Philippine Health Insurance Corp. (PhilHealth) are being directed to the pockets of corrupt officials and facilities through fraudulent claims.
An exclusive investigative report by this paper recently exposed the scam bleeding PhilHealth dry, through various schemes such
as overpayment of hospitals, the “upcasing” and padding of claims, ghost dialysis treatments, ghost patients and even fake members.
Since 2013, according to the Inquirer report by Jovic Yee, Leila Salaverria and Mariejo Ramos, PhilHealth has lost P154 billion due to handily exploited loopholes in its payment mechanism. About half of this amount, or P102.5 billion, was lost due to overpayment of claims, and others to bogus treatments and ghost patients.
With billions at stake, it is not hard to imagine the opportunity for corruption in PhilHealth. The Universal Health Care (UHC) Act, signed into law by President Duterte last February, mandates automatic health coverage for all Filipinos and the expansion of services.
As the implementing agency, PhilHealth is looking at even more tantalizing budgets — P217 billion in the first year of implementation, P257 billion by 2020, P271 billion by 2021, P286 billion by 2022, P302 billion by 2023, P319 billion by 2024 and so on.
These billions do not come only from government coffers, but from the monthly contributions coughed up by its contributors such as employees, professionals and self-employed and overseas workers who account for the bulk, or 30 percent, of PhilHealth’s 53.8 million members and 50.7 million dependents.
To fund the UHC, government had to raise taxes, while PhilHealth members saw a staggering 40-percent increase in contributions this year.
Even more sickening than the amounts lost so far is the system of fraud behind PhilHealth’s hemorrhage involving a particularly grisly scheme.
Whistleblower Edwin Roberto, who first sat down with the Inquirer for his exposé, disclosed that his former employer, WellMed Dialysis Center (WellMed) in Novaliches, Quezon City, had been filing PhilHealth claims for “ghost dialysis” of long-dead patients by forging the signatures of these dead individuals (shades of the Janet Lim-Napoles scheme that led to the pillage of P10-billion pork barrel funds).
PhilHealth insiders also told the Inquirer about other schemes, including upcasing, for instance of common cold or cough, to pneumonia. PhilHealth paid hospitals a staggering P11 billion for pneumonia last year, a 5-percent increase from P2 billion in 2010. But the Department of Health has not noted any pneumonia outbreak.
Dr. Minguita Padilla, former head executive staff of former health secretary Janette Garin, said hospitals and clinics would not be so brazen as to defraud PhilHealth without inside collusion. “The fraud in the health care providers will not proliferate, continue, flourish unless they have some help from inside, unless they have conspirators.”
A PhilHealth official pointed to a mafia inside PhilHealth that supposedly fosters a culture of fear, preventing personnel from exposing corruption.
Irregularities are not new to PhilHealth. In 2015, Senate blue ribbon chair Sen. Teofisto Guingona III held an inquiry into P2 billion lost to spurious claims by some eye centers, but no report or prosecution came out of it.
PhilHealth’s current president, Roy Ferrer, faces a complaint for conflict of interest at the Ombudsman for practicing his profession as a doctor and collecting PhilHealth payments while he is already a PhilHealth director. Its former head, Celestina Ma. Jude de la Serna, was earlier removed for excessive travel expenses.
Mr. Duterte has expressed indignation at the scam and, as of this writing, has reportedly asked the PhilHealth president and board members to submit their courtesy resignations. The “sheer amount of 100 something billion [pesos lost],” he said earlier, “is totally, totally unacceptable to me.”
As it is to all Filipino citizens, who have to depend on a robust, fiscally sound and efficiently run PhilHealth for their mandated health coverage.
The purge of this clearly unwell agency is a must, especially now that it is tasked with wider powers and bigger resources with the UHC’s enactment.
The implementing rules and regulations of the UHC — yet to be crafted — should contain stringent measures against fraud. And an independent body is needed to monitor the implementation of the law and the use of its funds; making PhilHealth in charge at this time, without benefit of a top-to-bottom process to expunge corruption and improve transparency, is like letting the fox guard the chicken coop.
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