PROSPECTIVE eye patients are first asked it they are PhilHealth members, and if so they are then brought to an eye clinic to undergo a cataract operation that is often not needed, PhilHealth president Alexander Padilla said on Wednesday.
Padilla was testifying in the Senate on the findings of PhilHealth’s own investigation on the modus operandi of the syndicates that led to the P2-billion PhilHealth claims for cataract operations in 2014.
He said he had suspended payments to two eye centers—Pacific Eye Institute and Quezon City Eye Center—which accused of engaging in the racket.
PhilHealth had paid P325 million worth of suspicious claims that allegedly went to the two eye clinics for cataract operations, and for which each PhilHealth member received P16,000.
Internal auditor Robert So showed that the insurance claims of Pacific Eye jumped from P69.58 million in 2013 to P169.49 million in 2014. The same claims of Quezon City Eye Center increased from P92.5 million in 2013 to P156 in 2014.
Padilla said some doctors in those clinics were misinforming patients that they needed an eye surgery for free even if they did not really need it.
“What’s important for them is to be able to get the money at the end of the process and not really to help. Oftentimes, patients do not know any better. The eye centers reap the benefits of claiming reimbursements from such activities,” Padilla said.
He said that, sometimes, the procedure was injurious as in the case of a patient who lost his vision after a doctor punctured his eye.
“We can only imagine the risks the patients of these facilities are being subjected to,” Padilla said.
He said they had identified 26 scam artists or “seekers” from six health facilities who had been named by patients who were lured to undergo cataract operations to deceive PhilHealth.
“The evidence gathered has shown that they demand kickbacks and commissions amounting to as much as P1,000 to P2,000 per eye per cataract surgery or laser from the surgeon and as much as P6,300 per eye per cataract surgery from Eye Center in exchange for bringing patients,” Padilla said.
“There have been reports of misinformation being propagated by certain seekers that entice PhilHealth members to undergo procedures that they are not well aware of.”
But David Gosiengfiao, the owner of Pacific Eye Institute, slammed PhilHeatlh for allegedly basing the fraud charges against the clinic on the Code of Ethics. He said they were now going through a difficult time because their reputation had been destroyed and payments had been stopped.
He said there was abuse of authority and trial by publicity.
Raymond Evangelista, the owner of Quezon City Eye Center, insisted that the insurance claims rose because even the professional fees of doctors were being coursed through it. Before 2011, he said, PhilHealth paid doctors separately.
“Naturally, our reimbursements ballooned,” he said.