CEBU CITY – Wrong interpretation of a circular issued by the Philippine Health Insurance Corp. (PhilHealth) led to fraudulent payments of coronavirus disease (COVID-19) claims, the National Bureau of Investigation Central Visayas (NBI 7) said.
According to NBI 7, PhilHealth’s Circular No. 9, which aims to establish guidelines for the implementation of COVID-19 benefits, was cited for the reimbursement of P333,519 in a patient’s bills.
This reimbursement was used by the NBI 7 as basis in filing criminal and administrative complaints before the Office of Ombudsman for the Visayas against high-ranking officials and personnel of PhilHealth 7 and Perpetual Succour Hospital, a private Cebu City-based medical facility.
“The hospital and PhilHealth, in our interpretation, they wrongfully interpreted the law and they covered probable cases even though there is already a negative test,” said lawyer Wenceslao Galendez, NBI 7’s supervising agent of COVID-19 claims cases.
Galendez said that, under the circular, COVID-19 claims may be made if the cases fall under “COVID-19 probable” and “COVID-19 confirm.”
Galendez said PhilHealth and the private hospital erred when a reimbursement of P333,519 was made in the bill of “Patient X”, who died last May 16 at the Perpetual Succour Hospital.
In the patient’s medical certificate, “Patient X” died due to acute respiratory failure type one secondary to community acquired pneumonia, inthrahepatic cholangiocarcinoma Stage 4 with hepatic carcinomatosis and COVID-19 probable.
Galendez explained that under PHilHealth’s circular, there are three cases that will cover a COVID-19 probable.
COVID-19 probable can be justified when the test was not conducted for some reason; the test was conducted, but the result was inconclusive; and when the test was conducted by a non-accredited testing center.
Galendez said “Patient X” should have not been declared a COVID-19 probable because he was tested thrice—twice through rapid tests and once using real-time reverse transcription-polymerase chain reaction (rRT-PCR).
All tests yielded negative results.
The rRT-PCR was conducted at the Allegiant Regional Care Hospital, which is accredited by the Department of Health (DOH) as a COVID-19 testing center, Galendez said.
“It is clear that it was not a COVID-19 probable because there were tests, and the patient tested negative. It will not cover probable and confirm. The COVID-19 probable was just made as an excuse,” said lawyer Renan Augustus Olive, regional director of NBI 7.
In a press briefing last Thursday, Oliva said the most telling piece of evidence that the NBI 7 discovered to prove the fraudulent claim was the exclusion of the rRT-PCR test in the documents submitted by the hospital to avail of the PhilHealth reimbursement.
“Let’s not just conduct rRT-PCR if they won’t use this in their basis for PhilHealth claims. The circumstances (of Patient X) does not fall under the circular,” Oliva said.
The NBI 7 has filed complaints for alleged 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 against 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 could also be administratively charged for dishonesty, neglect of duty and misconduct, the NBI 7 said.