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Tuesday, May 16, 2006
'False' PhilHealth claims
By Victor L. Camion
NEGROS Oriental Provincial Hospital and Bindoy District Hospital are in hot water over the complaints filed by Philippine Health Insurance Corporation (PhilHealth) for alleged false claims.
Provincial legal counsel Erwin Vergara said both PhilHealth-accredited hospitals would be investigated to clear the issue.
Vergara said the Provincial Government will not allow anybody to destroy its credibility and the people who committed the claims error must shoulder the responsibility.
He said the latest complaint (the fifth one) involving claims errors could prove to be the most damaging.
"The damage of the four other complaints was lesser," he said. "Those behind this should be responsible."
Vergara assured any person confirmed responsible for acting in bad faith for the purpose of claiming payments from PhilHealth will be dismissed from service.
But he believed that what happened was "an honest mistake" and was done in good faith arising from PhilHealth claim heavy workload.
PhilHealth accused the two hospitals of fraudulent practice for allegedly furnishing false or incorrect information to claim payment from the National Health Insurance Program.
In a complaint before PhilHealth's Arbitration Department based in Pasig City, PhilHealth prosecutor Enerito Yanez accused the two hospitals of allegedly extending the period of confinement of a patient and misrepresentation by furnishing false or incorrect information.
Unknowingly, he said, PhilHealth had paid the claims of both hospitals.
Yanez said Negros Oriental Provincial Hospital claimed to have admitted and confined the patient, Aquilino Estaño, Sr., on October 15, 2003 to November 3, 2003.
On the other hand, Bindoy District Hospital claimed to have confined Estaño on October 18 to 20, 2003.
The information, he said, clearly overlapped.
Yanez said the discrepancy was, however, uncovered during evaluation.
He accused said claims were highly irregular and improbable since no person can be in two places at the same time.
"Either or both of them had committed the offense of 'extending the period of confinement and misrepresentation by furnishing false or incorrect information,' in claiming benefits from complainant," said Yanez.
He said any health care provider who files a claim with extended period of confinement by increasing the period of actual confinement of any patient despite his actual discharge or absence will be penalized by revocation of accreditation.
In addition, he said, PhilHealth could also recommend to the Department of Health to cancel the license, accreditation, or clearance of an accredited hospital to operate.
Yanez said any health care provider would also be liable for fraudulent practice when, for purpose of participation in the National Health Insurance Program or claiming payment, it submits false or incorrect information.
He said the section penalizes the health provider with a P30,000 to P50,000 fine and its accreditation suspended for not less than one year but not more than two years.
If the misrepresentation leads to damage to the Corporation, the accreditation of the provider would be revoked, Yanez said.
"In addition, a recommendation shall be submitted to the DOH for cancellation of its license, or accreditation, or clearance to operate, as appropriate," he said.
No explanation
Yanez said after discovering the discrepancy, PhilHealth directed the two hospitals in separate letters dated November 25, 2005 to explain the irregularity but they failed "or refused to respond."
He believed the failure to answer the directive showed that both health care providers acknowledged their omission and violation.
"Because of the failure and/or neglect of both respondents to submit their respective explanation and evidence, complainant was constrained to institute the instant complaint in accordance to Rule 3, Section 13, of the 1997 Revised Rules of Civil Procedure," Yanez said.
(May 14, 2006 issue)
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