Upgrading cough to pneumonia cost PhilHealth billions

AFTER uncovering questionable cataract claims, the Philippine Health Insurance Corp. yesterday bared a possible new scheme to defraud it of funds, which involves “upscaling” a cough or a sore threat to a case of pneumonia.

PhilHealth president Alexander Padilla said the state-run agency would extend its probe to supposedly questionable pneumonia claims, after detailing before a Senate committee its various findings on the cataract cases it paid for.

PhilHealth’s biggest payouts go to pneumonia cases, for which it shelled out P7.6 billion in 2014. It pays out P15,000 for simple pneumonia and up to P32,000 for more complex cases.

Padilla told reporters that from initial reports, the practice was for patients who had cough or sore throat being diagnosed with pneumonia, which would require confinement.

There have also been suspicious instances where an entire family was diagnosed with pneumonia and confined in a hospital, he noted.

No payment

“What happens is that a cough or a sore throat is upscaled to pneumonia so that they could get our reimbursement of P15,000 or if with complications, P32,000, when in fact, there should be no payment from us if it would just be a simple cough,” he said in an ambush interview.

He also said looking into the pneumonia claims would be more difficult because PhilHealth officials would have to check out actual clinical findings and talk to patients.

Aside from pneumonia, PhilHealth’s biggest payouts go to hemodialysis, for which it paid P4.6 billion in 2014; ceasarian delivery, P4.2 billion, removal of cataracts, P3.7 billion, and maternity care package, P1.5 billion.

Also yesterday, Padilla detailed before the Senate Blue Ribbon committee the allegedly fraudulent practices it uncovered when it looked into cataract claims from surgical centers, including fraud, misrepresentation, and misinformation.

PhilHealth has already suspended payments to two eye centers.

Among the practices it found was the employment of “seekers” to look for PhilHealth members to entice them to undergo eye procedures, regardless of whether they need it or not. A total of 26 seekers were named, he said.

According to him, “solicitation is unethical based on the standards espoused in the law and the code of ethics for the medical profession.”

He also said that in some instances, patients were given care below acceptable standard or treated by doctors without the proper credentials, putting patients at risk.

There was a case where a patient who did not get proper post-operative management led to the removal of the eye and permanent blindness.

Fabrication of needs

There have also been times when there were fabrication of needs, or efforts to entice PhilHealth members to undergo procedures that they are not well aware of, such as cleaning the eyes or making them shiny for free. In this modus, recruiters are paid a commission.

There were likewise instances where seekers acted as syndicates, demanding kickbacks from reimbursements.

PhilHealth found a case where the doctor who performed the procedure was not the one who signed the claims form. In another instance, a doctor had a fabricated credential.

Raymond Evangelista of the Quezon City Eye Center, one of the centers whose payments from PhilHealth had been suspended, denied that it employs seekers to get patients for profiteering purposes.

Cataract reimbursements

Evangelista also said it should not be penalized for the actions of doctors outside the institution.

Evangelista also said the rise in cataract reimbursements was due to PhilHealth’s decisions to course doctors’ payments through the medical institution.

David Gosiengfiao, owner of the Pacific Eye Institute which also faced payment suspension, said his center does not employ a seeker, and instead has a liaison officer who gets in touch with senior citizens groups and nongovernment organizations to inform them of the center’s services.

Gosiengfiao also took the stance that advertising is not illegal for health institutions, and questioned PhilHealth’s reliance on the code of ethics of the Philippine Academy of Ophthalmology as if it was law, when this code can be amended any time.