SENATE majority leader Juan Miguel Zubiri yesterday bared major fraudulent incidents involving a “mafia” at the Philippine Health Insurance Corp (PhilHealth), which has been draining the corporation of its funds.
Corrupt practices at the state insurer, he said, were carried out through the interim reimbursement mechanism (IRM), a system used to assist hospitals in dealing with COVID-19 cases; non-existent and “ghost patients;” and legal and administrative cases, among others.
The incidents, which were made public by Zubiri during the second Senate committee of the whole hearing on anomalies at the agency, amounted to some P1 billion in questionable payments.
Zubiri said one of the incidents, which date back to 2014, involves anomalous claims and releases under the RIM wherein “favored” hospitals were paid their claims within 10 days after the filing of claims, as in the case of free-standing dialysis centers which were paid P226 million, and maternity care package providers receiving P4.7 million.
Zubiri lamented that government-run hospitals still have unpaid claims. These are Western Visayas Medical Center with P121 million; Ospital ng Maynila, P19.3 million; and Corazon Locsin Montelibano Memorial Regional Hospital, P41.7 million.
PhilHealth said it has already paid Ospital ng Maynila, which led Sen. Panfilo Lacson to ask PhilHealth for proof of payment.
Zubiri said another anomaly involves the case of the Pacific Eye Institute headed by a Dr. David Gosiengfiao, who admitted during a board meeting of PhilHealth in 2016 that he was asked by a certain PhilHealth officer to pay P7.3 million for the release of his claims amounting to P73 million for cataract surgeries.
Another incident involves the claims of the 18-bed capacity Golingay General Hospital located in Malalag, Davao del Sur, for non-existent patients, but was apparently paid by PhilHealth P18 million in 2014 and another P10 million in the first semester of 2015.
Zubiri said PhilHealth stopped the payment of additional claims after Golingay General Hospital was subjected to a post-audit investigation for the “striking figures in claims.”
Zubiri said also part of the incident was the questionable “active membership” of more than 5,000 PhilHealth members who are more than 100 years old.
OBSOLETE SYSTEM
PhilHealth president and CEO Ricardo Morales said cleaning the PhilHealth database is a continuing process, and takes time because of an obsolete system. He said this is the reason he insisted on upgrading PhilHealth’s information technology system.
Morales said he has ordered PhilHealth regional offices where these centenarians are registered and check on the local civil registry of the status.
Zubiri said that PhilHealth’s “ghost patients” incident also involved the payment of P4.24 million to WellMed Dialysis Center as mentioned by Sen. Panfilo Lacson in a privilege speech on July last year.
He said PhilHealth paid the dialysis centers for the unfinished session days of a patient who has died.
Zubiri also cited the case of one Pamela del Rosario and her parents who were all cancer patients from Region 1 (Ilocos), wherein a hospital was able to claim P1.7 million. He said 10 PhilHealth employees found involved in this irregularity were just charged with simple misconduct and the cases were eventually dismissed.
“Apparently, she and her parents were ghost patients as the hospital was able to claim P1.7 million. This is a well-documented case within PhilHealth. However, stringent action has yet to be done,” he added.
He said some hospitals defrauded PhilHealth by “upcasing” illnesses of their patients by declaring that a patient suffered a stroke when he or she only was diagnosed with hypertension. He said the hospitals charged PhilHealth as high as P25,000 per benefits claim.
He said some hospitals also have three to four “ghost patients” whose claims earn as high as P100,000 a week, while some hospitals pay people P1,000 to act as patients in order to claim for more serious ailments from PhilHealth.
“Other unscrupulous HCIs (health care institutions) would give a patient mere paracetamol and send them home. But they would charge PhilHealth for a room and medicines under that patient’s name and come up with a fraudulent or made-up illness claim,” he added.
Another incident involved the overpricing of information technology equipment, increasing as high as 12,400 percent the prices of equipment to be purchased. Based on the first Senate hearing, the PhilHealth’s IT sector’s overpricing could reached P734 million.
INACTION
Zubiri said other incidents involved the following: the PhilHealth legal sector will issue orders to ignore court rulings on fraud; file diluted cases against erring PhilHealth officials or employees; and prolong inaction on cases against erring hospitals.“Supreme Court and Court of Appeals decision on suspension of hospitals have remained unimplemented or ignored by PhilHealth,” Zubiri said, citing the case of the CA decision on Perpetual Succor Hospital n Cebu and the CA decision sustaining the suspension of the General Santos Doctors Hospital for being found guilty of claiming payments for ghost patients.
He said the case of Perpetual Succor remains un-enforced while the case of the GSDH has been put on hold.
PhilHealth officials present during the hearing has yet to be given the chance to answer the allegations as Zubiri ran out of time given him to ask questions on resource persons.
IRM QUESTIONED
Lacson questioned PhilHealth officials about their basis for approving the IRM as he said the board resolution that would be the basis of the IRM circular for COVID-19 cases came after the circular, instead of before.
“While PhilHealth circular 2020-0007 was dated March 20, the board resolution (PhilHealth Board Resolution 2515) was supposed to be its basis was issued on March 31… Paano nauna ang IRM circular for COVID-19 dated March 20, samantala ang board resolution ratifying the implementation of the issuance of that circular ay March 31 ? Paano nauna ang circular sa board resolution? (How come the IRM circular for COVID-19 dated March 20 came ahead of the board resolution which ratified the implementation of the issuance of that circular came out March 31? How come the circular came first instead of the board resolution?),” Lacson said.
Jonathan Mangaoang, PhilHealth board corporate secretary, said the basis of the circular was a resolution dated Jan. 30, 2020, to which Lacson said that even Health Secretary Francisco Duque III was not yet aware of the first known COVID-19 case in the country.
Lacson noted that while past issuances of PhilHealth were disseminated on the same day or the day after, the circular on IRM for COVID-19 cases was disseminated on April 22, or one month later.
“In an effort to justify, in-antedate nila (they antedated) to March 21. But the date of dissemination was April 22,” he said.
Lacson said he also learned that before PBR 2515 was passed, PhilHealth already released P703 million, and also released P9.299 billion before April 22.
Morales explained that some expediency had to be adopted, but PhilHealth board member Susan Mercado said they were not yet talking of COVID-19 as of end of January 2020.
Lacson said: “I remember the Wuhan couple, I think that was February. Naunahan nila ang unang COVID case, na-anticipate niyo na? (They were ahead of the first COVID19 case in the country, did you anticipate that?”).
The irregular disbursement of IRMs was one of the three main issues being investigated by the Senate committee of the whole.
Resigned PhilHealth anti-fraud legal officer Thorrson Montes Keith alleged that the PhilHealth mafia has pocketed some P15 billion through several fraudulent schemes, including the irregular disbursement of the IRM, overpriced purchase of IT equipment, and manipulation of financial statements.
BIGGEST RIM RECIPIENTS
To dispute allegations that the IRMs were misused, Roberto Labe Jr., PhilHealth’s legal counsel, said funds for the IRM were properly disbursed.
Labe disclosed that the Southern Philippines Medical Center in Davao City got the biggest piece of the pie with P326 million, followed by the UP-Philippine General Hospital in Manila with P263.3 million, Davao Regional Medical Center, in Tagum City, P209 million; Vicente Sotto Memorial Medical Center in Cebu City, P204 million; and Jose Lingad Memorial Regional Hospital in the City of San Fernando in Pampanga, P201 million.
National Kidney and Transplant Institute in Quezon City, P179 million; Baguio General Hospital and Medical Center in Baguio City, P165 million; Northern Mindanao Medical Center in Cagayan de Oro City, P150.2 million; Quirino Memorial Medical Center in QC, P150 million; and Eastern Visayas Regional Medical Center in Tacloban City, P164.2 million.
It can be noted that the regions with the most number of COVID-19 cases are the National Capital Region, Central Visayas, Southern Tagalog, Central Luzon, and Western Visayas.
WRONG DEPOSIT
Lawyer Thorrson Montes Keith, PhilHealth anti-fraud legal officer who resigned due to the discovery of corruption in the agency which was no acted upon, said two officers of PhilHealth in Region 2 “intentionally” deposited P9.705 million to the Rural Bank of Balanga in what he said was an apparent move to defraud PhilHealth.
Keith said two officers of PhilHealth based in Region 2 “inadvertently” deposited the money to the Rural Bank of Balanga in Bataan “without any valid reason.”
He said the two officers could not have made that error since a background check he made on them showed they were long-time PhilHealth employees who have technical expertise.
Keith identified the two as Editha Fonel, head of accreditation and quality assurance section; and Jerome Follante, social insurance officer 3.
“I learned in my investigation that Fonel and Follante were permanent employees of PhilHealth for years with technical expertise in their respective positions. So there should be no room for this kind of mistakes,” Keith said.
He said he learned that the P9.705 million was intended for deposit in a bank in Region 2 for the benefit claims of a hospital but “had been inadvertently credited the money to the Rural Bank of Balanga located in Bataan, Region 3.”
“I discovered that it was multiple transactions of payments of reimbursements of PhilHealth benefit claims for 12 consecutive periods for the month of May 2019– between May 2 to 22. This is not merely inadvertent as the multiple transaction connotes deliberate intent to defraud the government by embezzling P9.705M,” he added.
He said after a series of negotiations, the Rural Bank of Balanga agreed to return the money on the condition that it be paid P49,123 for the inconvenience brought about by the incident.
Keith said what was peculiar was why high-level PhilHealth officials did not order for an investigation in the incident as PhilHealth regional offices are not authorized to deposit money outside of its jurisdiction.
“Some people whom I asked information from in PhilHealth believe that Balanga Rural Bank case was just a decoy to cover up something bigger,” he added.
Keith said there were unconfirmed reports that a PhilHealth official has a mistress in Balanga, Bataan, and that another ranking official frequently travels in Balanga.
He said the best thing to do is to determine who owns the bank account at the Rural Bank of Balanga “and it will open a Pandora’s box.”
