4 docs, 3 hospitals rapped over fraudulent cataract claims
The Philippine Health Insurance Corp. (PhilHealth) has finally filed administrative cases against four doctors and three hospitals in Western Visayas in relation to irregularities in insurance claims for cataract surgeries.
Lawyer Jay Villegas, manager of the PhilHealth's Fact-Finding and Administrative Investigation Department, said the doctors and hospitals are facing a total of 34 counts of violating Republic Act 7875 (National Health Insurance Act).
The alleged violations include the submission of padded claims, misrepresentation, and violation of the PhilHealth warranties of accreditation.
Villegas refused to identify the doctors and hospitals that have been charged saying he is still seeking authority from PhilHealth Acting President and Chief Executive Officer Lorna Fajardo. But he said these were the same ones who submitted the highest claims for cataract surgeries.
PhilHealth last month 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.
The reported violations which were first reported in 2004 involve 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.
PhilHealth had also investigated a controversial scheme on the recruitment of patients through "seekers" or "recruitment agents" sent out by ophthalmologists in coordination with the hospitals where the operations are performed.
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).
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.
The Philippine Academy of Ophthalmology (PAO) said it was saddened by the filing of cases against their colleagues but welcomed the move of PhilHealth.
"It is painful but also necessary," said PAO national president Dr. Ma. Dominga Padilla in a telephone interview.
Padilla said they are ready to face their members who have been charged, "But if they are found to be guilty of the charges, they have to face the punishment in order to protect the insurance system and the integrity of the profession."