PhilHealth-Davao to probe upcasing in some Davao hospitals

AMID the issues hounding some of the hospitals around the country regarding the upcasing of simple diseases to Covid-19 to get larger health insurance claims, the Philippine Health Insurance Corporation (PhilHealth) in Davao Region said it has already observed some Davao hospitals doing such.

Dr. Hector Zenon Leonardo P. Malate, PhilHealth-Davao acting vice president, said they have anticipated such an issue to come out because of the huge amount of Covid-19 claims that is included in the PhilHealth's package.

"Actually, naa na mi na nakit-an nga mga possible upcasing pero imbestigahanan pa to, wala pa pud namo sila nabayaran. As of this time, wala pa mi nabayaran na Covid claims kay among gisigurado nga tanang claims or tanang gina-submit sa hospital e tinuod gyud nga mao na ilang sakit (We already have noted possible upcasing in some hospitals, but they are yet for investigation, and we have not yet released their claims. As of this time, we have not paid any hospitals for their Covid-19 insurance claims because we make sure that what they are submitting are true and correct)," Malate said in a mobile phone interview on Thursday, September 24, 2020.

He cited an example of a patient who is admitted today and the following day, the patient dies. If the hospital charged it as a severe Covid-19 case, which qualifies for a claim of more than P300,000 based on the PhilHealth's Covid-19 benefit package, without being able to thoroughly examine the patient, then they will surely conduct extensive investigation to determine whether the patient's case indeed falls under the severe Case of Covid-19.

"Among pangayoon, for example, ang clinical chart sa patient tapos among ipa-evaluate sa among doctor kung tinood ba gyud (We will ask for the clinical chart of the patient, then we will let our doctor evaluate it to determine whether the hospital's claims are true and correct,)" he said.

Malate also assured that hospitals in Davao who attempt to do such will undergo a rigorous medical pre-payment review (MPR) from their legal office.

"Although I already issued an advisory that all Covid-19 claims must be attached with the patient's clinical chart as we have already anticipated this, that's why I released a memorandum order that all Covid-19 claims must undergo MPR," he said.

MPR will identify whether the case is indeed Covid-19-related or if such, it will also determine whether these are mild, moderate, or severe cases of Covid-19.

According to PhilHealth Circular 2020-0009 or the benefit packages for inpatient care of probable and confirmed Covid-19 developing severe illness/outcomes, the package amount for mild pneumonia in the elderly or with co-morbidities is P43,997, while for moderate pneumonia is P143,267, for severe pneumonia is P333,519, and for critical pneumonia is P786,384.

MPR, under the PhilHealth provision, is only for the four illnesses, namely, Urinary Tract Infection (UTI), Pneumonia, Acute Gastroenteritis (AGE), and Sepsis. But there is a certain provision in the Circular's policy that Philhealth reserves the right to conduct MPR whenever it deems necessary.

He also said that those Covid-19 mortalities listed on the Department of Health-Davao's data will still undergo MPR for validation so that what the PhilHealth will be paying as claims will be the right amount from the PhilHealth package.


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