CEBU CITY—The Philippine Health Insurance Corp. (PhilHealth) in Central Visayas and a private hospital here were involved in the padding of coronavirus disease (COVID-19) claims.
This was the finding of the National Bureau of Investigation 7 which filed a complaint against officials and workers of PhilHealth and Perpetual Succor Hospital before the Office of Ombudsman for the Visayas on Thursday.
Charged before the Ombudsman for violation of the Anti-Graft and Corrupt Practices Act, Code of Conduct and Ethical Standards of Public Officials and Employees, and Malversation of Public Funds NBI-7 were eight PhilHealth-7 employees including, Arlan Granali (acting regional vice president), Dr. Francis Javier (HCDMD division chief), Dr. Joan Tiu-Ayuson (Benefits Administration Section chief), Josette Bacalso (Fiscal Controller), Dr. Reginal Mangubat (Benefits Administration officer), Anecito Ramas Jr. (Social Insurance Officer), Anthonneette Lerios Maamo (Benefits Administration clerk), and Kenneth Aguilar Donalvo (Social Insurance Assistant).
The NBI 7 also charged four workers of Perpetual Succour Hospital Inc. namely Sister Brenda Mondares (financial management manager), Gladys Sarmiento (assistant department manager), and billing officers Jaye Anne Carcueva Arañas and Gina Misagal.
The PhilHealth workers should also be administratively charged for dishonesty, neglect of duty, and misconduct, the NBI 7 said.
Lawyer Renan Augustus Oliva, regional director of NBI 7, said their two-month investigation showed that the PhilHealth and hospital officers connived in a fraudulent claim for reimbursement to PhilHealth in the amount of P333,519 in a patient’s bills.
Oliva said what the PHilHealth and hospital workers did was an example of upcasing or the fraudulent practice among healthcare providers in which benefits and claims were padded to collect higher reimbursements.
Oliva said the NBI 7 investigated the case of “patient X” who tested negative for COVID-19 thrice but was declared COVID-19 positive when he died last May 16.
They discovered the irregularity when the hospital did not include the result of the real-time reverse transcription polymerase chain reaction (rRT-PCR) showing that the patient was COVID-19 negative.
He said the hospital workers involved denied any wrongdoing.
“They had reasons which unfortunately did not support their allegation of valid claims,” said Oliva.
With the help of medico legal officer Dr. Rene Cam, the NBI 7 found that Patient X’s death was due to non-COVID-19 pneumonia.
“Claims for non-COVID pneumonia only amounted to P32,000. This is called an upcase because his claims were updated to severe COVID-19 in which the hospital can get P333,519 from PhilHealth,” Oliva said in a press briefing yesterday.
Oliva said they have called the attention of the hospital for failing to include the result of the COVID-19 test.
"When it involves public funds, we have to observe due diligence. The government will go bankrupt with this kind of activity," he added.
Oliva said the upcasing may have contributed to the high number of COVID-19 cases in Central Visayas.
The region has recorded more than 22,000 cases as of October 28.
Showing boxes of documents, Oliva said the NBI 7 is still investigating at least 100,000 cases involving anomalous COVID-19 claims.
“This is a very challenging task. We were tasked by the President to investigate and we will not back down from this task. Expect more cases to be filed in the coming days,” he said.
Oliva said more private hospitals in the region are involved in fraudulent COVID-19 claims.