PhilHealth-12 worried over fraudulent COVID-19 claims

GENERAL SANTOS CITY (MindaNews / 10 Nov) – The Philippine Health Insurance Corp. (PhilHealth) in Region 12 (Soccsksargen) has tightened the assessment of reimbursement for coronavirus disease (COVID-19) cases in the wake of the emergence of alleged fraudulent claims in other areas.

Dr. Hector Malate, acting PhilHealth regional vice president for Region 12 (Soccsksargen), said Tuesday they adopted a stringent medical pre-payment review system for COVID-19-related benefit claims to ensure that they only cover legitimate cases.

Under the system, he said health care providers are required to submit certified true copies of the clinical charts and other documents related to the treatment and management of the cases.

“We’re very careful in the processing of COVID-19 claims since the benefit packages or case rates are quite high. We have to properly scrutinize them before making any payment,” he said in a press conference in Koronadal City.

As of Nov. 5, Malate said they already received a total of 275 claims from various private and government hospitals in the region.

He said four of these claims worth P158,273 have so far passed the evaluation process and already paid or reimbursed by the agency.

A total of 80 claims were returned to the concerned hospitals, seven were denied while 184 others are currently on process, he said.

He said PhilHealth has the right to deny the payment of ineligible claims or place them under their appropriate case rates.

Malate, who assumed as acting regional vice president for Region 12 last Oct. 19 following a reshuffle ordered by President Rodrigo Duterte, said the agency is also working on the resolution of pending legal cases in the area.

He said they currently have a backlog of over 3,000 cases for submission of fact-finding investigation report and around 10,000 involving claims that are pending with their review committee.

The 3,000 pending cases involve overlapping claims submitted by hospitals, those with double filing, claims with deductions and accumulated premium collections from employers, he said.

The official said the 10,000 claims that are under review were previously denied by the agency and subjected to reconsideration.

For the pending legal cases, he said the regional office submits the fact-finding investigation reports to the central office, with the latter eventually determining if they warrant the filing of administrative cases.

Malate added that they coordinate the cases involving erring doctors and hospitals to the National Bureau of Investigation for the possible filing of criminal charges. (MindaNews)