Lack of transparency may have led to fraud at PhilHealth – PACC

Published August 6, 2020, 12:48 PM

by Genalyn Kabiling

Ghost membership, overpayment of medical claims, and other forms of insurance fraud have become possible due to lack of transparency and validation system in the Philippine Health Insurance Corp. (PhilHealth), according to Presidential Anti-Corruption Commission (PACC) Commissioner Greco Belgica. 

PACC Commissioner Greco Belgica

Belgica bared PhilHealth’s weak Information Technology (IT) system that allowed the alleged fraudulent acts ahead of the filing of corruption complaints against 36 PhilHealth officials before the Office of the Ombudsman. 

The anti-corruption agency intends to expand the PhilHealth investigation to cover other regions and may file cases against more officials involved in irregularities, according to Belgica. 

“Commission of insurance fraud is made possible due to lack of transparency and prior validation of claims of members and health care providers (HCP). 

PhilHealth merely conducts random post audit, thus, not every claim is audited. Only those claims which are apparently suspicious,” he said.

 “We will file the appropriate charges against those involved in the scam before the Office of the Ombudsman.” 

He noted that PhilHealth has spent billions of pesos on its IT system but “has remained fragmented, allowing fraudulent schemes to prosper.” 

Belgica also criticized PhilHealth for the lack of constant monitoring of the user accounts and their corresponding authorized access to the system lead to unauthorized access. 

Such loophole has given opportunities for PhilHealth employees to circumvent PhilHealth charter and rules and regulations, he added. 

“As a consequence thereof, there is incessant and perpetual overpayment and payment to ghost patients and members by PhilHealth,” he added. 

As a result of PhilHealth’s lack of validation and audit system, Belgica said the State health insurance corporation endured financial losses in overpayment and other fraudulent transactions. 

He noted that PhilHealth has lost more than ₱153 billion to fraud since 2013, roughly 30 percent of the total claims payment of ₱512.6 billion. 

The State-run health insurer has reportedly paid ₱102 billion in overpayment for claims. Belgica also pinpointed that several fraudulent schemes have been employed by some employees, health care providers, and members. 

On the “fraud by employees,” Belgica raised concern about “creations of ghost membership, irregularities in the conduct of the proceedings, fasttracking of claims, and procurement of IT projects.” 

Some health care providers could also commit fraud such as “upcasing, non-admitted patients, recruitment, over bed capacity, and multiple claims,” according to Belgica. 

Belgica likewise noted the “fake receipts” and “fake membership” alleged committed by some PhilHealth members. 

A partial PACC investigation report on PhilHealth’s alleged anomalies meanwhile has been submitted to the Office of the President. 

The first batch of corruption complaints is expected be filed before the office of the Ombudsman next week. 

“We are looking at around 36 officials at the moment. We expect the number to grow as investigation proceed to the regions,” Belgica said, without revealing the names of the concerned officials