Over ‘anomalous’ COVID-19 claims: 11 PhilHealth, CHH execs sued

CEBU, Philippines —  The National Bureau of Investigation (NBI)-7 has filed charges against 11 officials and personnel of the Philippine Health Insurance Corporation (PhilHealth-7) and Chong Hua Hospital in Cebu City before the Office of the Ombudsman over alleged anomalies and irregularities in PhilHealth claims for COVID-19.

NBI-7 filed cases in violation of the Anti-Graft and Corrupt Practices Act, malversation of public funds or property through falsification of public documents penalized under Article 217 of the Revised Penal Code, Code of Conduct and Ethical Standards of Public Officials and Employees, and Gross and Grave Misconduct against eight officials and personnel of PhilHealth.

Facing charges are PhilHealth-7 Acting Regional Vice President Arlan Granali; Francis Javier, Division Chief; Joan Tiu-Ayuson, MD, medical specialist; Josette Bacalso, fiscal controller; Reginald Mangubat, MD., medical specialist; Anecito Camahalan Ramas Jr., social Insurance Officer; Anthonnette Lerios Maamo, Clerk III; Kenneth Aguilar Donalvo, Social Insurance Assistant; and other unidentified respondents.

The bureau also filed cases against three officials and personnel of Chong Hua Hospital namely Sharon Rose Rosales, CHH PhilHealth Supervisor; Jasmine Miguel Finance, manager; and Tiffany Bertulfo, Assistant Vice-President for Finance for Anti-graft and Corrupt Practices Act and malversation of public funds or property through falsification of public documents.

The charges stemmed from NBI-7’s probe on alleged corruption and irregularities on PHilHealth claims of COVID-19 patients.

It probed the case of a 41-year-old patient who was admitted at Chong Hua last March 30, 2020 after experiencing shortness of breath or dysphea.

The patient was transferred to Vicente Sotto Memorial Medical Center the following day because the hospital bill at the private hospital has piled up. He was also subjected to RT-PCR test. The patient died because of kidney failure with Hepatic Encephalopathy and Acute Decomponsated Liver Cirrhosis as secondary cause.

However, NBI investigation showed that CHH filed a PhilHealth claim for the patient in the amount of P197, 883.52 anchored on the circulars of PhilHealth "to justify the claim despite being aware of the fact that the patient (patient's surname) has negative COVID-19 result.”

The NBI also said that the patient is not a health worker or frontliner during the period of his confinement at Chong Hua hospital.

"The testimonial and documentary evidence gathered in the course of the investigation are sufficient enough to arrive at one logical conclusion, that conspiracy had existed between Chong Hua employees/officers and PhilHealth employees/officers,” NBI-7 said.

The bureau also said PhilHealth officials failed to scrutinize the documents submitted and supporting attachment before their office but approved the same, allegedly in haste, thus payment was credited to the Chong Hua hospital account.

"By their failure to grossly perform their inherent supervisory review functions required of them by reason of their duties and responsibilities during the claim processing flow, PhilHealth employees and its officers had facilitated the misappropriation of public funds by approving claim payment to patient hospital bills when it should have been outrightly denied at the first instance," the NBI added.

Last October 2020, NBI first filed cases against PHilHealth officials and employees including those from Perpetual Succour Hospital for also allegedly committing fraudulent claims in PhilHealth.

Philhealth

PhilHealth-7 said, "We will answer the charges in the proper forum."

It said work will continue based on the guidelines in processing claim documents per published circulars of the corporation, which are developed by its policy-making sector and approved by the PhilHealth Board.

In a statement yesterday, PhilHealth-7 cited PhilHealth Circular 2020-0011 entitled “Full financial risk protection for Filipino health workers and patients against coronavirus disease (COVID-19),” which was published in a national paper.

“Prior to the publication of this circular, the Corporation issued PhilHealth Advisory No. 2020-022 posted in the PhilHealth website on April 2, 2020 up to present, which states that “Due to the growing public concern over the financial costs of getting treatment for the Coronavirus Disease 2019 (COVID19), please be informed that the Philippine Health Insurance Corporation (PhilHealth) will shoulder the full cost of treatment for all COVID-19 cases until April 14, 2020.”

After the date, financial coverage for COVID-19 cases are provided via recomputed case rate, said its Regional Vice President, Dr. Edwin Orina.

The reason for this accommodation window is the novelty and the wide range of severity of the disease for which no existing case rate or package based on accepted protocols has yet been established.

“PhilHealth is confident that by the above mentioned date, more about the behavior of the disease in the Philippines can be learned, a final protocol established, and an appropriate case rate can be developed that will provide adequacy and sustainability to the antiCOVID-19 campaign,” the agency said.

PhilHealth is set to issue a new set of guidelines that will include the appropriate case rate based on accepted protocols in dealing with the disease.

Chong Hua

In a separate statement, Chong Hua Hospital denies any mishandling of the Philhealth benefits of its patients and expressed disappointment in the NBI for giving merit to the allegations.

“We would like to conclusively state that our claims filing and reimbursement procedures for the implementation of COVID-19 benefits for inpatient care (for both probable and/or confirmed cases) are fully compliant with all PhilHealth circulars and guidelines,” the hospital said.

Even with the filing of the complaint, CHH is confident that a fair, impartial and politically unprejudiced investigation will absolve the hospital of any anomaly.

“For almost a year now, our institution and its healthcare professionals have been subjected to extreme pressure, to try and mitigate the challenges of an unprecedented pandemic,” it said.

Despite the challenges, the hospital said it continues to improve its patient care, testing procedures, quarantine facilities, and hospital capacity, as well as the health of its staff and rational use of resources.

“Our hospital was not exempt from the pandemic, confusion and the negative financial impact brought by COVID-19. Through it all, however, it was the principles and ideals of Chong Hua Hospital that served as our compass and anchor. Consistent with this foundation of values is the strict adherence to statutory and regulatory guidelines.”

The hospital assured its stakeholders and the communities that it will continue to serve and uphold its promise of “healing with passion, caring with compassion”.

Isolation

In a separate development, the Department of Health (DOH)-7 said it is set to discuss with PhilHealth the rules on isolation and recovery period of patients, which affects coverage of claims.

“We really need to sit down with PhilHealth. Very strict man gud and circular sa PhilHealth nga para mabayaran and usa ka facility, it has to be 14 days. That is one of our projects that we will meet and discuss about this concern and others about health care,” said Dr. Mary Jean Loreche, DOH-7 chief pathologist and spokesperson. — Caecent No-ot Magsumbol, JMO (FREEMAN)