Criminalizing fraudulent PhilHealth claims urged

CLARK FREEPORT – A former Philippine Health Insurance Corp. (PhilHealth) executive said here on Friday that it is time to further tighten the rules against fraudulent claims in health insurance filed by medical practitioners with the government firm by making them criminally liable.

During the media forum “Balitaan” organized by the Capampangan in Media, Inc. (CAMI) in cooperation with the Clark Development Corp. (CDC) and the Social Security System (SSS) at the Bale Balita here on Friday, Tito Mendiola, former PhilHealth senior vice president, said the tight measures should be implemented in the light of the rising incidents of suspected fraudulent claims filed by doctors with the government health insurance agency to protect the interest of the public.

Last year alone, PhilHealth paid a whopping P78 billion in insurance benefits. In the same year, 10 doctors filed health insurance benefit claims worth P500 million, according to Phil-Health chief Alex Padilla.

The huge amount claims triggered suspicions in PhilHealth that these were tainted by fraud especially after it was found that nine out of the ten doctors are ophthalmologists.

Mendiola said many insiders of the institution are convinced that at least five percent or P3.9 billion of the payments in 2014 were fraudulent claims.

“It is not unlikely that this has happened, too, in the preceding years,” Mendiola said.

This is a situation that must be corrected immediately if only to protect the people’s money, he added. PhilHealth’s core equity is contributed by the public, either directly or through the taxes and fees paid to the government.

What needs to be introduced are new provisions in the laws that would criminalize medical malpractice stemming from fraudulent claims for health insurance benefits which shall serve as the sole basis for cancelling the license of an erring medical practitioner, Mendiola said.

PhilHealth, in turn, must tighten its procedures in processing claims for medical insurance that would allow it to spot fraud, according to Mendiola, who also served as Floridablanca mayor and is “raring to throw his hat in the municipality’s mayoral contest in next year’s polls.”

Mendiola said Phil-Health must also enter into a multi-agency arrangement involving the Department Health (DOH), Department of Justice (DOJ, Professional Regulation Commission (PRC) and the ,Philippine Medical Association (PMA) “to effectively curb this malpractice.”

Earlier reports said Padilla has ordered a suspension of payments to the 10 doctors whose claims for health insurance benefits hit P500 million, pending clearance from a team of auditors tasked to validate the claims.

However, Raymond Evangelista, Quezon City Eye Center (QCEC) founder and CEO who was linked to the socalled “cataract scam,” said in a published statement on July 2 that the government suspended their payments “despite the absence of proof and an absolute disregard for due process.”

Evangelista said “patients are evaluated and processed by PhilHealth, which approves or disapproves them, and determines whether the applications are legitimate or not.”