PSH denies Philhealth fraud

TIP OF THE ICEBERG National Bureau of Investigation Central Visayas (NBI 7) Director Rennan Augustus Oliva vows to uncover more evidence of alleged fraudulent PhilHealth claims in the region by going over volumes of medical records of patients that were referred to PhilHealth by hospitals as Covid-19 cases. Considering that Cebu City was once the epicenter of Covid-19, Oliva admits this will take time. / Amper Campaña

CEBU City-based Perpetual Succour Hospital (PSH) has denied allegations made by the National Bureau of Investigation Central Visayas (NBI 7) that the hospital engaged in fraudulent activities involving Covid-19 Philippine Health Insurance Corp. (PhilHealth) benefit claims.

In a statement issued on Friday, Oct. 30, 2020, PSH legal counsel Jose Ray Bael said the hospital is “strongly confident” that the PhilHealth claim for Patient X, one of the cases investigated by the NBI 7, is above board as it was “based on the medical diagnosis of competent and respected medical professionals.”

“How can the FMS (Finance Management and Services) personnel who faithfully filed the claims based on the diagnosis and medical records be held responsible for fraud?” asked Bael.

The PSH statement also noted that the NBI found no reason or basis to indict the medical professionals who made the Covid-19 diagnosis.

“The claim was supported by medical records submitted to PhilHealth and passed scrutiny and applicable criteria set by PhilHealth,” the PSH statement further read.

Bael was referring to complaints filed by the NBI 7 on Thursday, Oct. 29, before the Office of the Ombudsman Visayas against four officials and employees of PSH and eight officials of the PhilHealth 7 over alleged anomalies in the hospital’s PhilHealth claims.

In a news conference on Thursday, Rennan Augustus Oliva, NBI-Central Visayas director, said there were instances when PSH patients who could have just been considered as ordinary pneumonia were referred to PhilHealth as Covid-19 cases.

Upcasing, as defined by PhilHealth, is a fraudulent practice of claiming for a related illness or procedure of higher severity than the actual to generate larger amounts of reimbursements.

Citing the case of Patient X, a stage 4 cancer patient who died on May 16, NBI investigators noted the patient was only confined for two days at the PSH and had tested negative for Covid-19 three times before.

The patient’s cause of death was listed as acute respiratory failure-secondary to community acquired pneumonia.

On July 19, the PSH submitted to PhilHealth a severe pneumonia benefit claim amounting to P333,519.

The claim was erroneously approved by PhilHealth according to the NBI 7.

Alleged violations

The 12 PSH and PhilHealth officials and employees were charged for violation of Republic Act 3019, or Anti-Graft and Corrupt Practices Act, Code of Conduct and Ethical Standards of Public Officials, and malversation of public funds.

Administrative cases were also filed against them for violation of the Revised Administrative Code for Dishonesty, Neglect of Duty and Misconduct, incompetence in the performance and inefficiency in official duties, and conduct prejudicial to the best interest of the service.

The PhilHealth officials charged with corruption were identified as Arlan Granali (acting regional vice president), Dr. Francis Javier (HCDMD division chief), Dr. Joan Ayuson (Benefits Administration Section chief), Josette Bacalso (Fiscal Controller), Dr. Reginal Mangubat (Benefits Administration officer), Anecito Ramas Jr. (Social Insurance Officer), Anthonneette Maamo (Benefits Administration clerk), and Kenneth Donalvo (Social Insurance Assistant).

The NBI 7 named Sr. Brenda Mondares (financial management manager), Gladys Sarmiento (assistant department manager), and billing officers Jaye Anne Arañas and Gina Misagal as the PSH respondents.

Bael said once the NBI complaint is served and received by the concerned PSH personnel, a detailed factual and legal counter-statement will be filed with the Office of the Ombudsman to prove their innocence and the total absence of fraud or malice in the preparation and submission of the PhilHealth claim for Patient X.

Bael said it was “unfortunate” that the NBI publicly announced the filing of cases against the four PSH officers and personnel before serving them a copy of the complaint and allowing them to answer the accusations.

“The public announcement through traditional and social media has shocked the PSH community,” he said.

Deeper probe

The NBI 7 investigation into suspected PSH and PhilHealth anomalies is only the beginning as the Bureau is set to evaluate more Covid-19 PhilHealth benefit claims across the region.

“The thrust of our investigation is per case, per patient. So, we go per patient. We will check if the claim was regular, in a sense that it was complete with documents. We will investigate all Covid claims,” Oliva said noting that Cebu City was once tagged as the epicenter of the coronavirus pandemic.

Oliva said the NBI will go over volumes of documents and get the medical opinions of their medico legal officers to help them in the course of the investigation.

“It will take a little time before we finish each case but we are working on it,” he said in a mix of Cebuano and English.

In the case of PSH, Oliva explained that the NBI would not have informed the public about the progress of their investigation if the cases had not yet been formally filed with the Office of the Ombudsman-Visayas.


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