PhilHealth-12 tightens watch on fraudulent claims

By | April 20, 2013

GENERAL SANTOS CITY (MindaNews/20 April) — The Philippine Health Insurance Corporation (Philhealth) in Region 12 has stepped up its monitoring of possible fraudulent claims from “unscrupulous” hospitals and doctors in the region.

Ramon Aristoza, Jr., Philhealth’s Area IV vice president, said in a statement that they are currently working on the implementation of more stringent evaluation and monitoring measures to help curb the cases of fraudulent claims in the area.

“The problem on fraudulent claims has remained prevalent in the 18 years of operations of Philhealth,” he said.

Region 12, which is under Area IV of the health insurance agency, comprises the provinces of South Cotabato, Sultan Kudarat, Sarangani and North Cotabato as well as the cities of General Santos, Koronadal, Tacurong, Kidapawan and Cotabato.

Based on their monitoring, Aristoza said the usual fraudulent activities include the padding of claims or making it appear that a member was confined beyond the actual days of illness, claims for non-admitted patients and the extension of the period of confinements of some members.


“Others do postdating of claims, misrepresentation by filing false or incorrect information, filing of multiple claims, unjustified admission beyond accredited bed capacity and fabrication of forms,” he said.

The official warned that erring hospitals and doctors could be charged with fraud and might lose their licenses if proven guilty of committing such malpractices.

“The employers may also be penalized for imposing unlawful deductions and failure to deduct and remit their employees’ contribution,” he said.

To help improve their anti-fraud measures, Arisoza said they recently held a consultation with multi-sectoral representatives and stakeholders in the region.

He said the gathering, the third activity nationwide that was organized for the purpose by Philhealth central office, was joined by Philhealth Executive Vice President and Chief Operating Officer Alexander Padilla and personnel from the agency’s Fact Finding Investigation and Enforcement Department (FFIED).

Aristoza said the consultation mainly focused on the presentation of FFIED¬¬¬¬’s fraud prevention and control program.

“It emphasized the role of accreditation and quality assurance as well as our legal service offices on the anti-fraud campaign at the regional level,” he said.

At the national level, Aristoza said the agency has yet to determine the actual financial losses incurred by the agency due to the fraudulent claims.

But he said it remained committed to totally eliminate the problem through regional level initiatives.

Despite the problem, the official assured that Philhealth is financially stable and capable of paying all the claims of local hospitals, provided that they rendered the necessary services to their members.

He said Philhealth presently has around P117 billion in reserve funds and is disbursing P1.3 to P1.5 billion every week for reimbursements. (Allen V. Estabillo/MindaNews)