PHIC, hospital officials sued over ‘irregularities’ in claims

CEBU, Philippines —  The National Bureau of Investigation-7 has filed criminal and administrative complaints before the Office of the Ombudsman in Central Visayas against eight officials of the Philippine Health Insurance Corporation (PhilHealth-7) and six personnel of a hospital in Cebu City over alleged irregularities in PhilHealth claims.

In its report submitted to Deputy Ombudsman for the Visayas Paul Elmer Clemente, the NBI-CEVRO fact-finding team has recommended the filing of criminal and administrative charges against  the following PhilHealth-7 officials and personnel: Arlan Granali, acting regional vice president; Francis Javier M.D, division chief-HCDMD; Joan Tiu-Ayuson, medical specialist; Josette Bacalso, fiscal comptroller; Anecito Camahalan Ramas Jr., social insurance officer; Anthonneette Maamo, clerk; Nina Christine Lunday, social insurance officer; and  Kenneth Donalvo, social insurance officer.

Also impleaded as respondents are personnel of the Adventist Hospital-Cebu: Dr. Michelle Jay Francisco-Napigkit, attending physician; Cefriano Julian Jr., chief of Patient Business Department; Ma. Kenneth La Sage, clerk of PhilHealth section; Dicchel Grace Napigkit, billing clerk; Red Ford Gargarila, billing clerk; and Romeo Rando Jr., registered nurse.

The NBI-7, in particular, filed criminal complaints against the respondents for violation of the Anti-Graft and Corrupt Practices Act and for malversation of public funds or property.

The bureau likewise charged the eight PhilHealth-7 officials and personnel with dishonesty, neglect of duty, misconduct, inefficiency and incompetence in the performance of official duties and conduct prejudicial to the service in violation of Executive Order No. 292 or the Revised Administrative Code of 1987.

The same officials and personnel are also facing charges for violation of R.A. 6713 o ang Code of Conduct and Ethical Standards of Public Officials and Employees.

Investigation

The complaint stemmed from an NBI investigation from a “randomly forwarded and approved PhilHealth claim” of the Adventist Hospital, in which the medical case of one of its patients was included.

The patient, who was said to be a retired bank employee, was admitted in the hospital last May 27, 2020 after experiencing cough and shortness of breath.

He was initially diagnosed of “ambulatory” and “acute respiratory failure secondary to pulmonary tuberculosis.”

He was then subjected to two COVID-19 tests—one for SARS-CoV2 antibody and another for RT-PCR.

The patient died a day after he was admitted.

However, the attending physician allegedly issued a certificate of death stating that the cause of death of the patient was “COVID pneumonia probable, severe.”

Yet the result of the antibody test of the patient, released on May 27 that year, turned out to be negative for COVID-19.

“However, despite the availability and knowledge of said negative result, Dr. Napigkit still certified and officially issued said death certificate with the cause of death ‘COVID pneumonia probable, severe.’ The same remarks were also reflected with other records of patient—including his medical certificate and clinical/ medical abstract which were issued and certified by the same attending physician,” read part of the report of NBI-7 submitted to the Ombudsman.

On June 3, 2020, the RT-PCR test result of the same patient was released and, just the same, it was also negative.

Despite the negative result, the documents forwarded to the Office of the Civil Registrar in Cebu City bore the same remarks -- that the patient died because of “COVID pneumonia probable, severe.”

The NBI-7 said the hospital personnel “in one way or the other prepared the PhilHealth claim documents and used the false death certificate as basis when they submitted the same to PhilHealth and continuously pursued to claim the benefit package amounting to P333, 519.”

Had PhilHealth-7 officers and employees thoroughly examined the records submitted by the hospital, NBI-7 said, they would have found the two negative results, which could have been the basis of their denial of the claim.

NBI said this is “clear case of upcasing or the claiming of a related illness or procedure of higher severity to gain higher benefit payment.”

The FREEMAN tried to contact Adventist Hospital for comment but the management said it will not issue a statement pending official communication from the Ombudsman.

PhilHealth-7 is also yet to issue a statement on the matter.

This is not the first time cases have been filed by the NBI-7 in connection to alleged irregularities in PhilHealth claims during the pandemic.

The bureau had earlier pressed charges against employees of two other hospitals and officials of PhilHealth for similar violations. — JMD (FREEMAN)