A CITIZEN Participatory Audit (CPA) conducted late last year has uncovered bogus claims made in 2021 by hospitals in Metro Manila and Rizal province against the COVID-19 Inpatient Benefit Package Program of the Philippine Health Insurance Corporation (PhilHealth).
A survey of 247 respondents revealed 13 or 5.26 percent were listed as having been listed as COVID-19 patients and confined in hospitals but denied having availed themselves of the PhilHealth benefit.
While the number might look small, the audit report said the 247 respondents were only a small sample of the total 6,746 claims against PhilHealth during the covered period.
PhilHealth paid the hospitals a whopping P1.387 billion for all of those claims combined.
Based on the breakdown provided in the 50-page report, the North Branch of the PhilHealth Regional Office NCR and Rizal accounted for 68.75 percent or 4,638 of the claims equivalent to P925.09 million.
Central Branch reimbursed 1,135 claims worth P247.7 million while South Branch only had 973 claims which was paid P214.17 million.
A printed copy of the CPA report was submitted on Dec. 28, 2023 to the office of PhilHealth president and chief executive officer Emmanuel Ledesma Jr.
Under the benefit package, COVID-19 patients with mild pneumonia in elderly patients or those with co-morbidities were entitled to claim up to P43,997 PhilHealth assistance in their bills. Those with moderate pneumonia were entitled up to P143,267. COVID-19 patients diagnosed with severe pneumonia got up to P333,519 while those listed as critical pneumonia had up to P786,384.
Auditors said among those who took part in the survey were respondents who said they were not COVID-19 cases.
“Of the 13 member-patients who claimed non-availment, 10 asserted they were not COVID-19 patients at all. The 10 patients reported suffering from other illnesses such as severe stroke, kidney failure, and lupus,” the audit tam said.
The other three said they were not even admitted or confined in hospitals, which should have made them ineligible to claims from the PhilHealth COVID-19 package.
Only two tested positive for COVID-19 while one did not have any trace. All three said they remained in isolation either in designated isolation centers or at home.
“Some respondents, representing deceased patients, asserted that standard protocols for COVID-19 deceased patients (e.g., no wake before the funeral, mandatory cremation) were not followed, suggesting these cases were possibly misrepresented as COVID-19 to avail of the benefit package,” the COA said.
While the report did not identify which hospitals filed the questionable claims or how much they were paid by PhilHealth, the list was narrowed down to 60 hospitals in NCR and Rizal where the respondents received medical attention.
The audit report said of the 247 respondents, 28 were treated at the Dr. Jose N. Rodriguez Memorial Medical Hospital and Sanitarium in Caloocan City.
The rest were given medical care at the Chinese General Hospital and Medical Center (25), Manila Doctors Hospital (15), San Lazaro Hospital (13), Medical Center Manila Inc. (12), Metropolitan Medical Center (12), and 54 other health care institutions (142).
“We recommended that PhilHealth top management direct the PRO NCR & Rizal to conduct a thorough investigation into the cases of the 13 member-patients who reported not having availed of the COVID-19 inpatient benefit package,” the COA said.
In its comment to the audit findings, the PhilHealth said the medical records of the 13 member-patients who reported not having availed themselves of the COVID-19 inpatient benefit package will undergo a secondary review by the Benefit Administration Service (BAS).
“If these claims do not meet the Corporation’s criteria for COVID-19, alternative applicable case rates will be applied. Additionally, these benefit claims have been forwarded to the Legal Unit for further investigation,” PhilHealth told COA.
