PHILHEALTH INSIDERS BEHIND DOUBLE CLAIMS
Fake claims and fictitious members are bleeding the national health insurer dry. Reforms have been introduced to stop the fraud, but other rackets in the company thrive, including ‘hoarding’ members’ contributions.
(First of a series) At first, employees at the regional office of Philippine Health Insurance Corp. (PhilHealth) in Dagupan City, Pangasinan province, paid no attention to visits by Pamela DizonDel Rosario.
After all, Del Rosario was frequently introduced to them by Maria Erilene Dizon-Zarate, their assistant human resources manager, as her sister.
But the two women’s relationship and their links to PhilHealth soon came under investigation by the state health insurer and the National Bureau of Investigation.
The PhilHealth regional office in Ilocos had sought the NBI’s help in investigating fraud in the company, specifically double claims and fictitious members, that was discovered in 2014.
Pamela del Rosario case
Among the cases investigators looked into were the claims of Del Rosario, a PhilHealth member.
According to PhilHealth sources who asked not to be named for fear of reprisal, Del Rosario’s fraudulent claims using fictitious members illustrate how employees and officials of PhilHealth themselves are exploiting holes in the company’s system to steal millions of pesos in government funds and members’ contributions.
Del Rosario’s case is “just the tip of the iceberg,” they said.
The NBI investigation stemmed from a memorandum from Dr. Francisco Soria, acting senior vice president of PhilHealth’s health finance policy sector, to the vice president for the Ilocos region, asking the regional office to verify what looked like “double claims” involving certain members appearing in the company’s computerized claims application, known as “N-Claims System.”
A random pick drew Del Rosario’s name from among the suspected cases of fraud, mainly because her name appeared as a frequent claimant.
Subsequent verification showed she made a total of 27 claims under her name for three supposed patients over four years—from 2010 to 2014.
P1.17M collected
Throughout this period, Del Rosario was able to collect a total of P1.17 million from PhilHealth for her chemotherapy treatment for breast cancer, as well as those of her “parents,” who she claimed had been seeking treatment for cancer.
A report by PhilHealth investigators, a copy of which was obtained by the Inquirer, showed that Del Rosario faked the treatments for patients who turned out to be fictitious using falsified hospital records and pharmacy receipts.
According to PhilHealth sources, Del Rosario pulled off the scam with help from conniving PhilHealth employees and officials.
At the core of the scam was Del Rosario’s sister, Zarate, who allegedly used her employee’s access to PhilHealth’s database as well as her connections in the company.
Using her inside connections, Zarate managed to enlist Del Rosario as a PhilHealth member, modify her online membership record, including adding her supposed parents—Federico and Corazon del Rosario—as dependents, and make claims for their cancer treatment.
A check with the Philippine Statistics Authority showed Federico and Corazon del Rosario were not her parents.
Two Pamela del Rosarios
Further, documents showed that two people named Pamela del Rosario appeared in PhilHealth’s computer database— the real Pamela del Rosario, whose birthdate was April 27, 1977, and a fictitious Pamela del Rosario, whose birthdate was April 27, 1978.
“That has been the scheme. They just change small details in real members’ identity, such as changing the spelling of their names or altering a digit in their birthdates,” a PhilHealth source said.
Del Rosario made “glaring errors” in filling out forms for her fake claims, sometimes making herself as the member but writing other people’s birthdates as hers.
But despite the errors, Del Rosario was able to collect payments of as much as P49,000—P1,000 shy of the threshold amount for the authority of a higher accountable officer—for each fictitious chemotherapy treatment.
Using fake documents, Del Rosario managed to get the claims approved by PhilHealth officials and checks issued under her name.
Worse, she filed claims and collected payment even before she became a member of PhilHealth, records showed.
“Her claims are given preferential attention because of the ‘fast track’ tag,” a PhilHealth source said.
On the surface, PhilHealth officials cutting corners to expedite payment of medical benefits looks like a positive practice.
Overeager sister
Under this practice, some special claims are marked “fast track” and pushed with a marginal note from the higherups, which should be a notice to PhilHealth employees not to delay payment.
But eagle-eyed PhilHealth employees began to take notice when Zarate constantly followed up her sister’s repeated claims.
Records showed that Del Rosario’s claims were quickly processed by PhilHealth, with checks issued to her in as short as five days—a far cry from the standard 60-day wait for most PhilHealth claims, according to company sources.
Del Rosario managed to collect payments using official receipts and confinement records supposedly issued by Nazareth General Hospital in Dagupan City.
Nazareth, however, issued a certification stating that neither Del Rosario nor any of her supposed dependents were confined or treated in the hospital. (See related story on this page.)
PhilHealth member Del Rosario also used official receipts from the Dagupan branch of a popular drug store chain, this time with the help of another “sister,” Maria Lourdes Dizon-Salvacion.
The pharmacy’s management issued a certification stating that the receipts were recorded as lost.
Claims scrutinized
For claims, PhilHealth members are usually asked to submit proof of their membership, along with documents showing the expenses incurred, as well as hospital confinement records.
The documents are reviewed and scrutinized at three layers in PhilHealth before the claims are approved and vouchers and checks are issued.
Every claim goes through PhilHealth’s health care delivery management division and the benefit administration section for approval.
For obvious reasons, Del Rosario’s fake claims slipped past the sentinels of the health insurance fund in Ilocos.
Employees at the regional office on Monday declined to be interviewed for this report.
An employee at the legal office told the Inquirer to go to the PhilHealth main office in Manila for comment.
On Tuesday, PhilHealth spokesperson Shirley Domingo said the employee involved in the Pamela del Rosario case was dismissed on June 29, 2016, for “grave misconduct and serious dishonesty.”
“Among the penalties imposed were perpetual disqualification to hold any public office, cancellation of eligibility and forfeiture of retirement benefits,” Domingo said in a text message to the Inquirer.
To prevent a repeat of the fraud, Domingo said, PhilHealth introduced reforms, including no longer accepting directly filed claims except for such conditions as peritonial dialysis, animal bite, hospitalization abroad and “other special cases.”
PhilHealth mafia
The scam pulled off by Del Rosario is just one of the thousands involving fraudulent claims and fictitious members, allegedly maintained by a mafia within PhilHealth, company sources said.
The scam does not include other rackets run by other departments, such as corruption in the accreditation of hospitals, and alleged “hoarding” and nonremittance of members’ contributions, the sources said.
“We really feel sorry for members whose hard-earned contributions are squandered by unscrupulous PhilHealth personnel who are expected to safeguard the corporation’s finances,” a source said.