Philhealth penalizes six hospitals, doc

The Philippine Health Insurance Corp. recently disaccredited three hospitals for fraudulent claims, and fined three others for illegal charges. A doctor also was fined for denying Philhealth benefits to qualified members.

Delisted by Philhealth were Ancheta Clinic and Hospital in Vigan, Ilocos Sur; Tabanera Medical Hospital, Cagayan de Oro City; and Amarille Dominos Hospital, Surigao City. The state agency’s board of trustees upheld earlier decisions of health insurance arbiters against the hospitals.

Ancheta Clinic was found to have filed confinement reimbursements of patients who were never admitted, extending the hospitalization periods of others, and padding claims. Tabanera Medical was proved to have filed false information on a claim and also for hospital refund of an out-patient, according to the website www.philhealth.gov.ph.

Aside from revoking Amarille Dominos’ accreditation, the directors also recommended cancellation of its license by Health Secretary Manuel Dayrit Jr., also Philhealth chairman. It was found to have filed refunds for non-admitted patients and for lying in its defense. The hospital had claimed confusion among patients, since it and Grace Christian Clinic and Hospital in Dinagat Island are owned and run by the same persons. Philhealth regional officers in Northern Mindanao refuted this, asserting that the two are "separate and distinct – with different locations, Philhealth code numbers and health department licenses."

Fined P20,000, P10,000 and P25,000, respectively were Brokenshire Integrated Health Ministries Inc. (BIHMI) in Madapo Hills, Davao City; Western Mindanao Medical Center (WMMC), Zamboanga City; and West Visayas State University Medical Center (WVSUMC), Iloilo City.

BIHMI was penalized for filing overlapping multiple refunds for a patient’s confinement way back in 1999, first on Dec. 1 and again a week later. BIHMI admitted to the lapse, but the Philhealth board ruled this was not enough to rid it of liability under the National Health Insurance Act of 1995. The law invests Philhealth with quasi-judicial powers over accredited hospitals and doctors.

WMMC was sanctioned for collecting fees from members to process their Philhealth refunds, which should be free of charge. One patient cried about being charged P100. On spot inspection by field men, another patient confirmed being charged the same amount. WMMC claimed the bill was for messengerial services, but the official receipts clearly stated "claims processing". It was ordered to return the money.

WVSUMC was found to have filed overlapping refunds over one confined patient. This was discovered when the patient’s hospitalization, starting July 18, 2000, was extended for the purpose of making a claim. It turned out that the person was confined in another hospital in the same region during the extended period.

Fined P25,000 was Dr. Abelardo P. Palaypayon of Far Eastern University-Nicanor Reyes Memorial Foundation Medical Center in Fairview, Quezon City. He allegedly refused Philhealth benefits to member-patients. To a patient’s complaint, the surgeon had claimed that the discount he gave on professional fees included the refund due from Philhealth. He was unclear on the waiver, however, as to who will receive the Philhealth benefits, the website posted. Without it, "the law is clear that since the surgeon’s professional fee has been paid in full, then the member stands to receive the benefit payment," according to Board Resolution No. 767 of Jan. 27, 2005. Palaypayon was ordered to refund the patient P14,000 representing the member’s Philhealth benefits.

Philhealth has 69 million members, 31 million of whom are indigents sponsored by local governments. It lists most hospitals and 18,955 doctors as "health insurance partners".

Some members, hospitals and doctors have attempted to defraud Philhealth in the past. in two instances, two hospitals claimed refunds for hysterectomy on patients who turned out to be males. Others bloated the quantity of medicines administered to patients, for refunds.

Dr. Francisco Duque III, Philhealth president and vice chairman, admitted this week that Philhealth lost P520 million in fraudulent claims in 2004 alone. The figure may be only 4 percent of P13 billion that Philhealth paid out in benefits last year and 1 percent of its P52-billion assets, "but it’s still a waste," Duque said. The agency is thus auditing all claims made even many years back. Over 300 cases are being investigated in Mindanao alone.

Fraudulent health insurance claims is a worldwide malady. In the US, 10-12 percent of refunds are bloated or falsified either by patients or doctors or hospitals. In 1995, one out of every three claims filed or paid by Medicare, Philhealth’s predecessor, was false.

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For the record, according to ex-Quezon congressman Oscar Santos, Agusan del Sur’s copra production during the coconut levy years 1973-1982 was only 0.02 percent of national production. This is why governors of the 67 other coconut provinces are opposing the grant of P8.4 billion, almost a tenth of the levy collections, to the Agusan Reserve Development Project.

The project will raise seedlings of hybrids that grow faster and bear more fruit. The governors want such R&D farms dispersed in all regions. Santos proposes a formula for equitable division of the levy: provincial copra production in 1973-1982 divided by national production multiplied by the levy amount to be distributed. The records are extant at the Philippine Coconut Authority.

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