PhilHealth sues dialysis center, admits widespread 'ghost treatments'

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Officials of the Philippine Health Insurance Corporation (PhilHealth) on Thursday say their agency has filed administrative cases against a dialysis center found to be claiming benefits for nonexistent kidney treatments.

Metro Manila (CNN Philippines, June 6) — State insurance fund officials on Thursday said they have filed administrative cases against a dialysis center supposedly claiming benefits for nonexistent kidney treatments.

Roy Ferrer, acting president of Philippine Health Insurance Corporation (PhilHealth), said they have found "strong evidence" that the dialysis center in Novaliches, Quezon City has been defrauding the state insurance fund since 2016. PhilHealth said the medical center has been under investigation and has not been paid since February.

"The corporation (has) filed 28 counts of administrative cases for claims for non-admitted, treated patients, misrepresentations by furnishing false or incorrect information, and breach of warranties of accreditation, performance, and commitments against the mentioned dialysis center," he said in a media briefing. "We acted upon this case and not sitting on it."

Four doctors were also charged with the facility.

Rodolfo del Rosario, PhilHealth senior vice president for legal sector, said they have directed PhilHealth's Metro Manila office to file criminal charges at the regional trial court.

Del Rosario confirmed claims of the whistleblowers on the practice of the identified dialysis center. He said the center claims all free 90 dialysis sessions annually even if the patient has already died by faking signatures.

He said they only give two dialysis sessions per week even in critical cases, while the dialysis center claimed for three or more sessions per week. One dialysis session costs from ₱2,800 to ₱4,000.

Israel Francis Pargas, senior vice president of PhilHealth's health finance policy sector, said adjudicators can verify if claims are consistent with rules. He said an additional form, Claim Form 4, is required so PhilHealth can evaluate the circumstances of admission.

But Pargas said for this case, PhilHealth has no database of signatures to cross-check.

"Admittedly, sa PhilHealth, wala naman kaming [we do not have the] database of all the signatures of all patients," Pargas said. "Kaya nanawagan din po kami katulad ng sabi ng Presidente na [That's why like the president is calling for earlier,] we really need the help."

Ferrer admitted that aside from 'ghost' kidney treatments, there are more cases of fraudulent treatment claims made by other individuals and hospitals that slipped past them.

"Malawak na malawak. Sa cataract pa lang, marami nang ini-imbestigahan. Hindi lang 'yun, meron pang capsulectomy na kine-claim ng erring opthalmologist. Meron pang 90 dialysis centers. Meron pang surgeons na gumagawa ng false claims sa incision at drainage,” Ferrer said.

[Translation: It's widespread. In cataract, there are many cases being investigated. It's not only that, there's also capsulectomy claimed by erring opthalmologists. There are also 90 dialysis centers. There are surgeons who create false claims for incision and drainage.]

As PhilHealth gathers evidence against these cases, the state health insurer's acting president encouraged the public to report fraudulent acts.

Senator Risa Hontiveros, a former board member of PhilHealth in 2014 to 2015, sought a probe on the alleged misuse of the insurance agency's funds.

"The gravity of the recent allegations should prompt government to check if every peso under the PhilHealth is indeed being used in a manner compliant with laws and the PhilHealth's mandate. We cannot allow fraud and greed to impede the effective delivery of health services to the people," she said in a statement Thursday.

She said fraud and abuse in the government's health insurance system should be addressed before the Universal Healthcare Act is implemented.

"The funds under our national health insurance program are supposed to empower our people especially the poor and bring them closer to affordable and effective healthcare. Any misuse of these funds is a betrayal of this vital mission, and must be stopped," Hontiveros said.

Demolition job?

Ferrer, who was appointed by President Rodrigo Duterte in July 2018, said there may be what he called a mafia in the agency with him as target because of his focus against fraud . He said erring employees used the same tactic against then PhilHealth President Jude dela Cerna.

“Maglalabas ang mafia ng paninira [The mafia will release defaming statements] because they want to take my place, but they have to earn it. My position is upon the discretion of the President,” he said.

Ferrer said 38 employees, some middle managers, have been suspended for various offenses. He said he has asked the help of the Civil Service Commission to reassign erring PhilHealth officials.