The House of Representatives committee on public accounts will look into at least P14 billion in advanced payments the Philippine Health Insurance Corp. (Philhealth) has made to hospitals for COVID-19 cases despite the suspension of additional fund releases.
“We will examine those payments in detail for any sign of fraud and/or overpayment. We have already asked Philhealth to submit all supporting documents,” the panel chair, Anakalusugan Rep. Mike Defensor, said.
Elsewhere, two former officials of PhilHealth have agreed to disclose details of the anomalies hounding the state insurer, an official of the Department of Justice (DOJ) said Saturday.
In a press statement, DOJ spokesperson, Undersecretary Markk Perete, said the individuals, who requested anonymity, have informed the Task Force PhilHealth during its meeting on Friday of the different fraudulent schemes allegedly employed through the years by PhilHealth
officers and employees, both in its main and regional offices, in collusion with some doctors and hospitals, and even banks, which act as remittance centers.
"These schemes include the payment of false or fraudulent claims against the corporation, malversation of premiums, and the exploitation by some unscrupulous personalities of the case rate system and the interim reimbursement mechanism, among others," Perete said.
Defensor said his panel would begin with the P1 billion that Philhealth had claimed had been liquidated or supported with documents by hospitals and other healthcare facilities that received advances.
“We hope to get by next week the supporting papers, which should indicate the amounts advanced, the recipient-hospitals, amounts liquidated, number and classification of new coronavirus disease cases, number and names of patients, medicines given, and the treatment patients received,” he said.
Philhealth has reported it has allocated P30 billion for COVID-19 cases, of which P14 billion has been advanced to health facilities. Of the P14 billion, P1 billion has been liquidated.
Defensor said the reported suspension of additional releases apparently covers the remaining P16 billion.
He warned hospitals to be careful in liquidating and treating as payment the P14 billion Philhealth had advanced to them.
The state-owned health insurance earlier set “case/package rates” for COVID-19 cases: P43,997 for mild pneumonia, P143,267 for moderate pneumonia, P333,519 for severe pneumonia, and P786,384 for critical pneumonia/coronavirus disease.
Defensor said based on the estimate of the Commission on Audit, there was at least a 20 percent “overpayment” in the case of package rates.
“20 percent of P14 billion is P2.8 billion. That is the potential loss from the amount Philhealth advanced to hospitals. We will watch out for any sign of overpayment or excess payment or claims in the documents we have asked from Philhealth,” he said.
He said health facilities should not make a reimbursement/payment claim for a “package rate” of almost P44,000 for mild pneumonia if it treated a patient only for cough, colds and fever.
“Theoretically, a hospital can do that, and it happened in many cases in the past. But now we are watching,” Defensor added.
Justice Secretary Menardo Guevarra, meanwhile, said the scope of the task force's work would include "the completion of any ongoing investigations or special audits, and resolution of any pending cases, regarding PhilHealth irregularities (which) will be expedited."
"At the same time, Task Force PhilHealth, as a composite group, will initiate fresh investigations on alleged anomalies that are not the subject of any ongoing investigation or audit," Guevarra said.
He said they would focus on identified centers of fraud within the state health insurer and certain regional PhilHealth offices that have been "notorious for years."
"We’ll collaborate with the legislative committees conducting probes in aid of legislation to speed up our work and avoid unnecessary duplication, so that we may take legal action immediately," Guevarra said.
He added the task force would conduct lifestyle checks on past and present PhilHealth officials "whose names have been repeatedly mentioned by witnesses and resource persons."
The task force will also invite resource persons who have highlighted abuses and flaws in the corporation’s Legal Department and Information Technology office that allegedly made the proliferation of these schemes possible.
Before the hearing, members of the task force – convened by Guevarra upon orders of President Rodrigo Duterte – met to discuss administrative and logistical matters relating to their work.
They agreed to conduct hearings as a whole, even as member agencies continue their respective investigations and audits.
However, it was agreed that any action by the agencies regarding PhilHealth would be coordinated through the task force, and any action towards the prosecution of PhilHealth officers and employees and their cohorts would be made through the task force and with the endorsement of Guevarra.
The participating agencies in the task force also reported the investigations currently pending with them and those that they have conducted to expedite the completion of their work with the assistance of the task force
They likewise agreed to harmonize efforts in the lifestyle checks that are underway and to be conducted by the different offices and agencies.
Guevarra is the convenor of the task force, which is composed of representatives of the Office of the Ombudsman, Commission on Audit, Civil Service Commission, Presidential Anti-Corruption Commission, Office of the Special Assistant to the President, Anti-Money Laundering Council, National Bureau of Investigation, and National Prosecution Service.
Meanwhile, PhilHealth clarified the interim reimbursement mechanism (IRM) was not only for COVID-19 patients, but for an overall pandemic response.
PhilHealth said Saturday the cash advance system not only covered COVID-19 patients’ benefit claims but also for HCIs’ overall response to the pandemic.
In an interview on Dobol B sa News TV, PhilHealth spokesperson Shirley Domingo said there was “no favoritism” in handing out IRMs to HCIs.
The IRM is a system where the PhilHealth pays hospitals and healthcare facilities in advance for insurance claims, to ensure that they could function in crises.
The PhilHealth defines the IRM as "a special privilege for the provision of substantial aid to an eligible Health Care Institution (HCI) directly hit by fortuitous event with clear and apparent intent to continuously operate and/or rebuild the HCI in order to provide continuous health care services to adversely affected Filipinos."
Implementation of the IRM amid the pandemic has been heavily questioned by senators as dialysis centers and maternity clinics have apparently been prioritized compared to hospitals that are actually handling COVID-19 cases.
PhilHealth president and CEO Ricardo Morales earlier explained that the 90-day historical claim of hospitals was used as the basis for the IRM allocation, pointing out that the amounts were not arbitrarily decided.
Data released by the state insurer showed that Davao City-based Southern Philippines Medical Center got the highest amount of cash advances so far from the IRM, with P326 million. With PNA
