3 hospitals may lose accreditation over fraudulent claims

MANILA, Philippines — Three hospitals in SOCCSKARGEN are facing possible revocation of accreditation with the Philippine Health Insurance Corp. (PhilHealth) for allegedly making fraudulent claims in the past three years.

Rodolfo del Rosario Jr., PhilHealth senior vice president for legal sector, said they have submitted evidence of fraud against the three “big hospitals” to the National Bureau of Investigation (NBI), which is looking into the anomalies of the agency.

He said the hospitals, which he refused to identify, were found to have questionable claims amounting to “tens of millions of pesos” based on the report of the Machine Learning Identification, Detection and Analysis System (MIDAS), a software used to analyze if the volume of claims made by accredited health facilities or medical professionals are “statistically improbable.”

“Based on MIDAS reports, the WellMed case will pale in comparison to these hospitals,” Del Rosario noted during PhilHealth’s Kapihan with Media forum.

One of the schemes the hospitals allegedly used is to raise the number of cases that were supposedly served for a particular illness.

“For instance, there are 3,000 cases of a particular illness while in the rest of the country it is only 300 cases. So there must be something wrong,” Del Rosario hinted.

Among dialysis centers, “WellMed is 800 plus (in the list) in terms of volume and amount of claims,” he added. WellMed is now the subject of an investigation by the Senate and the NBI for allegedly making fraudulent claims amounting to P154 million. 

Although the PhilHealth regional office in SOCCSKARGEN was already instructed to file criminal complaints against hospital officials, PhilHealth president and CEO Ricardo Morales clarified that they are not looking at a blanket cancellation of the accreditation of the three hospitals.

“We may cancel the accreditation of certain operations or services involved in questionable claims.  We don’t want to revoke the accreditation of an entire facility because we don’t want our members to be disenfranchised,” Morales said.

He added that PhilHealth has been automating its operation to effectively reduce false claims.

“Our anti-fraud mechanism is inadequate.  It’s like a fish net that has big holes. We need a finer net and in automation, it is supposed to provide that,” Morales also said.

He revealed that the agency is also investigating 23,000 “possible frauds” committed by accredited health facilities and medical professionals. 

Describing the huge task of PhilHealth, he claimed the agency is now handling about one million claims a month with 10,000 of them coming from the National Capital Region alone.  

“We pay out P10 billion to P12 billion a month so you can just imagine the size and complexity of operations.  We have about 10,000 accredited hospitals and other health facilities. So, this is a very complicated and enormous system,” Morales explained.

After introducing MIDAS in 2018, the investigation rate of PhilHealth has increased by 300 percent.

But Morales said because of the “size and complexity” of PhilHealth’s tasks and its shortage in manpower, there are still “limitations” to what the system can do. 

He maintained that while “automation is the solution (this) will not happen overnight.”

PhilHealth, he stressed, intends to address “corruption, incompetence and inefficiency.”  

Meanwhile, 21 PhilHealth executives yesterday decried their implication by the NBI in the P1.8-million fraudulent claims of WellMed Dialysis Center.

In a statement read by Lolita Tuliao, PhilHealth branch manager for National Capital Region Central, the officials noted that the NBI’s “accusation is all sweeping” and that they consider this as “irresponsible and insensitive since we are clearly being subjected to trial by publicity.”