PhilHealth admits issue remains 'clear and present danger for the nation'
Remember the "cataract scam-scheme" primarily blamed on some P4 billion in government losses of the Philippine Health Insurance Corporation (PHIC)?
PHIC in a report now summed up the "important facts and events," disclosing drastic reform measures and passage of significant policies. Of late, insiders added, an in-house overhaul of section chiefs was also ordered, with the legal department "experiencing" much of the changes.
And since last year's full-blown investigation, PhilHealth Acting President and Chief Executive Officer (CEO) Lorna Fajardo laid down the agency's suspects alongside actions taken thereat.
Six Ilonggo eye specialists were repeatedly named in the report alongside two local hospitals, all for padding of claims, misrepresentation and Breach of Warranties.
The report was addressed to Representative Janette Loreto-Garin (First District, Iloilo) with Fajardo admitting, "controversial claims in cataract surgeries have been a monumental concern of the Corporation.'
"Admittedly, it has been a grave concern not only because of its seeming threat to the sustainability of the National Health Insurance Program, but more importantly, to the clear and present danger our members are exposed to if the proliferation of these anomalous claims on cataract cases continues," Fajardo wrote.
The report laid down longtime PhilHealth suspicion that eventually led to the SEACREST Report in 2000.
Exposed here was the "systematic Medicare fraud" blamed on "certain professional health care providers in Negros Occidental through rampant solicitation of cataract patients and charging them to PhilHealth."
In fact, Fajardo in said report cited, the fraud was realized through a socio-civic organization "as the proponent in the unethical practice utilizing medical missions or charitable work as their modus operandi."
And as early as October 2000, formal complaints were then recommended against Ilonggo eye specialists Dr. Fortunato Eusebio, Dr. Rolando Lee and Dr. Miguel Tomas Sarabia.
However ensuing arbitration made by PhilHealth's Legal Services Group led to the dismissal of the case with refunds made by the trio in 2004.
Then came a similar report in August of 2005 when PhilHealth Regional Office 6 raised the signals against "alarming increase of claims" for cataract surgeries in Western Visayas.
Thereafter, PhilHealth validated the report and to date, Fajardo confirmed the filing anew of complaints this time against four Ilonggo doctors and two local hospitals.
Named respondents by PhilHealth were Drs. Leopoldo Cuaycong Jr., Miguel Sarabia, Nonito Avecilla and Danilo Guanzon. Hospital complaints were filed against Bacolod Our Lady of Mercy Specialty Hospital and Bacolod Adventist Medical Center.
Fajardo said filing of formal charges against the respondent professionals and hospitals have been recommended with cases now scheduled for hearing with PhilHealth's Arbitration Department.
Meantime, PhilHealth also disclosed "intensive daily monitoring of selected hospitals" nationwide. These hospitals out for check will come from PhilHealth's "watchlist."
One of those in the region thus far subjected to daily monitoring is Bacolod Our Lady of Mercy Specialty Hospital. The inspection team Fajardo reported, "was able to cite drastic decrease of cataract patients admitted since November 2007 up to the present based on admission records."
Further still, the hospital's "Optha Ward" has reportedly closed "or ceased operation…extensive report on the monitoring to be submitted."
With the new policy reforms, PhilHealth placed a cap of 100 surgeries of cataract to be performed by a cataract surgeon in a year or 25 surgeries in a quarter.
"Exceed of the cap shall be tantamount to inclusion of the professional in the watchlist; inclusion in watchlist shall merit close monitoring and scrutiny of claims filed," the PhilHealth safety net now provides.
To recall, at the height of the scam-scheme, PhilHealth probers uncovered a minimum of 30 and maximum of 120 cases per day on the claims of eye doctors involved.
"The aforementioned developments and courses of action are just the initial steps already undertaken which are included in the general anti-fraud program of the corporation," Fajardo said.
PhilHealth since 2002 filed a total of 1,415 complaint-affidavits against erring institutional and professional health care providers.