PhilHealth woes

A new scandal has erupted courtesy of a new whistleblower. A former employee of a WellMed dialysis center in Quezon City has exposed that the center continues to submit claims at PhilHealth even when the patient has already expired.

This scam is now being called "Ghost dialysis" akin to ghost employees. There really is no shortage of how creative Filipinos label scams and controversies. According to the law, PhilHealth members have ninety free dialysis sessions per year.

However, when the patient dies, the dialysis center should no longer submit claims for whatever balance remains of the ninety free sessions. Apparently, WellMed does. President Duterte has already ordered the arrest of the owners of WellMed, also promising to rehabilitate the state health insurer to protect it from fraud.

It seems PhilHealth does not have a process to check if a member is getting his treatments or not, or even when the patient dies. Claims are simply processed, as long as the member is active. The patients themselves are not concerned with the paperwork, for as long as they get their free treatment. Only when an audit is made, if PhilHealth already suspects fraud, are the scams exposed.

Dialysis is not the only treatment where PhilHealth is also conned into paying up. When doctors submit claims, they are required to indicate the illness. Every illness or condition has a case rate by which PhilHealth agrees to pay a set amount.

The anomalies occur when unscrupulous doctors indicate a condition with a higher case rate than what is actually ailing the patient, in order to be paid the higher fee. PhilHealth again does not confirm if the patient actually has the disease submitted by the doctor as it would be impractical to check each and every patient. Again, it is only when an audit is done do the fraudulent transactions emerge. With the number of doctors in the country, how can they all be monitored?

In the planned rehabilitation of PhilHealth, everyone should be involved in accountability. The connivance of some doctors and PhilHealth should also be investigated. A scam does not last long without connivance. This means that hospitals/centers, doctors and especially patients must know what is going on when it comes to PhilHealth claims. When a patient dies, the family should inform PhilHealth as soon as possible to prevent claims being continually submitted.

PhilHealth should also put safeguards in place such as random audits to flush out fraud. PhilHealth has long been the milking cow of fraudulent medical practitioners. The “ghost dialysis” certainly is not the first. There was a time when PhilHealth was clamping down on cataract surgeries due to numerous frauds. I would not be surprised at the amount of one hundred fifty-four billion pesos lost in PhilHealth over the years. The Universal Health Care Law will soon be implemented. More dialysis sessions will soon be offered. If PhilHealth does not put in place stronger measures against fraud, those who cannot help but take advantage of the government will do so with a vengeance. Easy money always attracts, no matter how supposedly honorable the profession.