PhilHealth stops payment of cataract claims
The Philippine Health Insurance Corp. (PhilHealth) has ordered a stop to payment of claims for cataract surgery during medical missions and through recruitment schemes amid reports of irregularities in claims of hospitals and doctors involving hundreds of millions of pesos.
In Circular No. 17 series of 2007, PhilHealth Acting President and Chief Executive Officer Lorna Fajardo ordered the discontinuance of the payments covering all claims for cataract operations with admission dates starting Nov. 1.
The circular cited as basis the PhiHealth Board Resolution No. 1046 series 2007, which directed the office to employ necessary measures to limit the number of claims for the procedure which may be compensated.
The circular did not cite the specific reasons why the payments for the claims have been stopped but it was issued amid persistent reports of alleged padding of PhilHealth claims for cataract operations and irregularities in the recruitment of patients.
PhilHealth investigators are looking into complaints and reports of alleged irregularities in cataract operations charged to the government insurance system. The alleged irregularities involve hundreds of millions of pesos in claims paid to hospitals and ophthalmologists in Western Visayas related to cataract operations.
The PhilHealth is also investigating complaints that the hospitals and doctors padded their claims to maximize payments by including medicines and services that were not availed of by the cataract patients.
Deception
A PhilHealth position paper on the cataract cases dated Aug. 1, 2005, a copy of which was obtained by the The New Today, said the patients are recruited and screened "in the guise of free medical outreach programs" through "recruiters-agents" sent out by ophthalmologists in coordination with the hospitals where the operations are performed.
While targeting mostly PhilHealth members and dependents, the organizers do not openly explain to their patients that it would claim and PhilHealth will be paying for the hospital expenses. Non-PhilHealth members are advised to enroll as voluntary members to wait for their eligibility period or else shoulder the operation cost, according to the paper, which is based on results of an investigation conducted by the PhilHealth Western Visayas office.
"The information about free surgery was not true and thus constitutes deception," it said.
The position paper said the patients who were easily attracted by the promises of free operation, meals, transportation and accommodation are then transported to hospitals in Bacolod City. It pointed out that these recruitment campaigns are being done without having the proper coordination with PhilHealth.
The recruiter-agents, including barangay officials, health workers and even a secretary of an ophthalmologist, were reportedly paid P300 for each patient, according to the position paper.
The mass recruitment and operations of cataract patients have become very lucrative for some hospitals.
Multi-million claims
PhilHealth paid 19,145 cataract-related claims reaching around P390 million to hospitals and doctors in Western Visayas from January 2004 to June 2007, according to data from PhilHealth’s Corporate Planning Department.
These include P66,989,720 in 2004 (3,477 claims), P123,516,910 in 2005 (6,203 claims), P140,241,210 in 2006 (6,538 claims) and P58,885,130 from January to June this year (2,927 claims).
The report noted that of the 3,771 cataract related claims in 2004, 2,601 claims were filed by two Bacolod City-based hospitals alone.
The Our Lady of Mercy Specialty Hospital filed 1,818 claims and was paid P39,921,202.92 while the Dr. Pablo Torre Memorial Hospital filed 783 claims and received P12,267,235.40 from PhilHealth.
Doctors performing these cataract operations are also earning millions of pesos from PhilHealth.
In 2006 alone, PhilHealth paid P48,491,030 in professional fees to 10 doctors in Western Visayas for eye-related operations, according to PhilHealth data from a source who asked not be identified.
One ophthalmologist received P15,778,650 for 2,071 claims while the next highest paid got P14,226,450 for 1,825 claims. These equal a monthly average ranging from P1.1 to P1.3 million in earnings.
During the same year, the government insurance corporation paid P78,411,289 to 10 hospitals in the region for eye-related claims.
The Bacolod Our Lady of Mercy Specialty Hospital received the biggest payment reaching P46,736,765.41.
In 2005, PhilHealth paid P55,205,869.48 for eye-related cases to hospitals and P38,542,620 in professional fees to doctors.
Unethical
The Philippine Academy of Ophthalmology (PAO) has decried the manner of getting patients by using recruiters-agents or "seekers." PAO has 1,300 members and 10 regional chapters.
"It is unethical, said PAO national president Dr. Ma. Dominga Padilla, in a telephone interview.
Padilla said the practice violates provisions of Academy’s Code of Ethics and Implementing Rules and Guidelines.
PAO has asked PhilHealth for an official report with a list of ophthalmologists whom they have found to be utilizing cataract patient seekers. The report should include whatever evidence PhilHealth has on the doctors and whatever complaints they have received concerning these doctors.
Under probe
Lawyer Jay Villegas, manager of the PhilHealth's Fact-Finding and Administrative Investigation Department, said two hospitals and two doctors in Western Visayas are being investigated for possible abuse of the insurance system. He declined to identify the doctors and hospitals saying this might pre-empt their findings.
Cataract-related claims of all patients of doctors in Western Visayas are also being validated, said Villegas.
Villegas said that they found 10 possible padded claims when they sampled 50 patients randomly selected from patients of 10 doctors in Western Visayas who have performed cataract operations.
He said they will file charges against hospitals and doctors found violating Republic Act 7875 (National Health Insurance Act). Violations will be a ground for the non-renewal or revocation of accreditation of doctors and hospitals and the imposition of a fine from P10,000 to P50,000.
Administrative charges could also be filed before the Professional Regulatory Commission for the cancellation of professional license of doctors found guilty.
Villegas said criminal charges for falsification of documents and estafa could also be filed against the hospitals and doctors.
Congressional inquiry
Meanwhile, a Resolution has been filed before the House of Representatives calling for a congressional inquiry on controversial claims and reimbursements from PhilHealth.
Introduced Wednesday last week, at least forty solons signed the Resolution entitled "Resolution directing the proper committee of the House of Representatives to conduct an inquiry in aid of Legislation, on the alleged fraudulent claims being made to the Philippine Health Insurance Corporation."
Among the solons confirmed by TNT to have affixed their signatures were Iloilo First District Representative Janette Garin and Pangasinan Third District Representative Rachel Arenas. Also in the House move were Northern Samar First District Representative Paul Daza and Parañaque Second District Representative Roilo Golez.