Philhealth on ‘ghost dialysis patients’

 BEHIND THE SCENES

Alfred P. Dizon

Hereunder is a press statement of the Philippine Health Insurance Corporation on “ghost dialysis patients” and fraudulent claims filed with PhilHealth:

PhilHealth has been handing out social health benefits to Filipinos for over 24 years. Its coverage spans from select outpatient procedures to treatment of simple to life threatening medical disorders.

 The Corporation offers its beneficiaries financial access to quality health care. However, PhilHealth’s compassion is not reciprocated by some of its partners. Instead some chose to milk the National Health Insurance Program (NHIP) of millions in funds.

Today, allegations of spurious dialysis claims came out in a major newspaper. A certain dialysis center in Novaliches (Quezon City) is said to have been defrauding PhilHealth by filing claims on behalf of their dead patients as far back as 2016. The Corporation does not condone such acts as it undermines the people’s entitlement to one of their basic rights as human beings – the right to appropriate medical care.

In relation to this case, the Corporation has filed 28 counts of administrative cases for claims for non-admitted/treated patients; misrepresentation by furnishing false or incorrect information; and breach of warranties of accreditation/performance commitment against the mentioned dialysis center. Also we have filed several counts of offenses against doctors for possible involvement between November and December 2018.

Through its communication campaigns, PhilHealth strongly encourages the participation of its members against fraudulent practices of its institutional and professional health care providers, and even employers.

The Corporation commends the whistleblowers for heeding the call of their conscience and stopping the deceptive scheme of the said dialysis clinic. PhilHealth is pleased that its members are now more empowered to join the battle to help protect the program and its funds.

The current PhilHealth administration will not back down in its crusade to suppress fraud. Its partnerships with the National Bureau of Investigation,

Professional Regulation Commission, Philippine Hospital Association, and Philippine Medical Association are pivotal to this grand undertaking. Under its present leadership, PhilHealth will not let thievery, in any form, prosper.

The Corporation is instituting reforms to fast-track the resolution of these cases. Our Board of Directors has approved the hiring of additional human resource to ensure speedy identification and resolution of cases. Reforms in the quasi-judicial functions are also given careful deliberation to solidify the impending improvements.

Recently, the requirement of Claim Form 4 (CF4) for all admissions starting March 1, 2019 did not only facilitate claims evaluation but also promoted accuracy and reinforced validation to ensure quality services given to our members, and deter fraud.

In addition, the HCI Portal serves as a capable complement to the CF4. It determines a patient’s eligibility to PhilHealth benefits or the requirements needed should one be deemed as ineligible to receive social health insurance coverage.

The automation of claims processing through the Electronic Claims brought the national average turn-around-time to only 17 days. This efficiency helps PhilHealth in maintaining consistent service delivery while bringing delight to its health partners by way of timely reimbursements.

PhilHealth cannot possibly keep its anti-fraud efforts going if it fails to instill discipline among its ranks. Efforts are currently being intensified to cleanse its ranks against officials and employees who are out to destroy PhilHealth's reputation and gains because of their resistance to reforms and reassignments which are long overdue.

The Corporation sees the need to sustain a clean slate if others are to treat its anti-fraud campaign seriously. Moreover, keeping an honest workforce would elevate performance standards while garnering trust of the publics that PhilHealth serves, especially now that the enforcement of the Universal Health Care Act is right around the corner.

All of us must take on the mantle of accountability and responsibility in protecting the NHIP. We must confront the detractors that are poised to destroy the gains of PhilHealth. The program exists for the sick Filipinos needing appropriate medical attention. We should do everything in our power to keep it out of harm’s way.

No overpayment

in payments

The alleged 'overpayments' made in claims amounting to P154 billion in the past six years are “efficiency gains,” a feature in the case rates payment system that the agency is implementing.

It also allows PhilHealth to effectively impose the No Balance Billing (NBB) policy for sponsored program members admitted in ward or ward-type accommodations in government health care institutions. The state agency is currently paying its health care providers using case rates, a fixed amount that covers both hospital and professional charges.

The newspaper report has alleged that PhilHealth’s increasing payments for pneumonia from 2010 to 2018 have reached “epidemic proportions” when there was no outbreak of pneumonia declared by the Department of Health.

PhilHealth points out that data reports of DOH are figures based on public health units/ facilities, while PhilHealth’s claims statistics are based on actual payments of claims made to its health care providers. So both figures cannot be compared.

In the particular case of pneumonia, figures are based on those that have actually sought treatment for the ailment in both private and government hospitals nationwide.

No review of ACR, upcasing

Contrary to the report, the case rates have been revised, following a study that saw the need to adjust the rates accordingly. For instance in 2017, PhilHealth came out with new costings for pneumonia. It also adjusted the rates for its hemodialysis payments from P4,000 to P2,600 per session to properly compensate dialysis centers. PhilHealth has also expanded coverage from 45 to 90 sessions in a year.

"Our partners are even clamoring to increase our case rates because they find them paltry and measly. What should concern us is the tendency of a few unscrupulous providers to defraud the government, particularly in the case of upcasing, ghost patients and fabrication of claims,” Dr. Roy B. Ferrer, PhilHealth Acting President and CEO pointed out.

The heart of the issue now lies in these cases of fraud,” he added, reiterating that PhilHealth’s intensified drive against fraud and abuse in and outside of PhilHealth is gaining momentum, and so these pernicious practices that sap PhilHealth’s fund will soon be a thing of the past. The funds stolen by these violators could have been otherwise utilized to expand the benefits or increase its payments to really needy patients.

The problem the reporter might be alluding to is the practice of some health providers to pad their claims and therefore collect higher reimbursements. “This practice is called ‘upcasing’.

In the case of pneumonia, a facility can ‘upcase’ a simple cough or cold by inventing a false claim for pneumonia. So they collect higher reimbursable amounts from P15,000 to P32,000,” the PhilHealth chief said, adding this is “criminal!”

Dr. Ferrer noted that the newspaper reporter’s sources quoted a 2014 Audit Observation Memorandum of the Commission on Audit (COA) for Northern Mindanao, which reported that PhilHealth overpaid by 20 percent in all cases it processed.

It could have been better if the reporter updated his figures, which should be a good policy in reporting.

“As fully explained by one of our senior officers in the same report, the case rates are so designed such that facilities can “win some and lose some.” If these facilities are efficient in patient management, they would be able to save on costs and gain from the reimbursements process to offset those losses when they fail to contain costs in other patients.

“This is also applicable to public hospitals which bear the rest of the costs under the No Balance Billing policy,” Ferrer further explained. “In cases where they gain, these should not be considered overpayments, because the bundled payments are provided for by law”.

Campaign versus fraud

The article also claimed that of the P154 billion, PhilHealth lost some P51.2 billion due to fraud between 2013 and 2018, even using an estimate of 10 percent being a global standard in measuring extent of fraud in health insurance payments.

“The article is only half of the story. It must be remembered that there is no health insurance system in the entire world that is fraud-free,” explained Dr. Ferrer, “and the ‘ten percent’ standard is applied when no efforts are exerted by the insurer to correct leakages. That may be true with some insurers, but I dare that this is not the case with PhilHealth,” Ferrer emphasized.

Fraud control measures and reforms were instituted to curb fraud. Investigations were intensified, and the regions conducted spot checking of health care providers. Benefit payment reforms to deter fraud were also set up. These cover pre-authorization of cataract operations and Z Benefit claims, implementation of PhilHealth dialysis database, validation of multiple claims and validation of deceased patients, and implementation of Claim Form 4.

There is more. It includes medical pre-payment review and the establishment of MIDAS or the Machine Learning Identification, Detection and Analysis System to detect over utilization, and system enhancements to detect common patterns of fraud.