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DOCTORS, whom government officials linked to a “cataract scam,” lamented the actions against their clinics by the Philippine Health Insurance Corp. (PhilHealth).
“We firmly believe that several actions of PhilHealth against us are unjust and laden with prejudice,” Raymond Evangelista, Quezon City Eye Center (QCEC) founder and CEO, said in a statement issued on July 2.
PhilHealth recently suspended reimbursements by QCEC because of suspicions of fraud and unethical marketing activities.
The government did “this despite the absence of proof and an absolute disregard for due process.”
“Pending the completion of their audit and investigation, we have been forced to close down indefinitely.”
Testifying at the Senate on Wednesday, PhilHealth President Alexander A. Padilla said syndicates at the QCEC led to the P2-billion PhilHealth claims for cataract operations in 2014.
He said clients had to undergo a cataract operation that is often not needed.
He added that he had suspended payments to QCEC and the Pacific Eye Institute that he accused of engaging in what he called a “racket.”
Evangelista said they are not “seeking” patients as Padilla alleged.
“Seeking patients is a detestable, unethical and illegal practice where doctors solicit patients who do not observe certain procedures for profiteering purposes.”
He also denied the center is engaged “in any illegal marketing activity and any attempt to prove otherwise is futile because it simply isn’t true.”
Evangelista explained the QCEC does not have its own set of doctors.
“The Center simply provides facilities for the eye doctors, helping out in their passion to provide health services for those who need them the most. Moreover, PhilHealth pre-approval forms contain certifications from visiting doctors that there was no ‘seeking’ involved in acquiring the patients they bring to the Center.”
Padilla said they had identified 26 scam artists or “seekers” from six health facilities who had been named by patients who were lured to undergo cataract operations to deceive PhilHealth.
“The evidence gathered has shown that they demand kickbacks and commissions amounting to as much as P1,000 to P2,000 per eye per cataract surgery or laser from the surgeon and as much as P6,300 per eye per cataract surgery from Eye Center in exchange for bringing patients,” Padilla said.
Evangelista, however, denied this, saying patients are evaluated and processed by PhilHealth, which approves or disapproves them as well and determines whether the applications are legitimate or not.
“It should also be noted that our Center only operates on those that have been cleared and pre-approved by PhilHealth. We can even go as far as to say that we are duty-bound to proceed with the operations, because of the PhilHealth approval.”
He said it was the large rise in cataract reimbursements, which brought about the initial sense of suspicion and doubt.
He said the P156 million that PhilHealth had reimbursed to QCEC in 2014 is wrong and misleading.
“Beginning September 2013, because of the all-encompassing case rate, PhilHealth began coursing doctors’ professional fees for almost all procedures through health care institutions and this is the reason why there is a jump in reimbursements. We only received a total of P68.9 million for the facility in 2014, not P 156 million.”
He said if the professional fees of the doctors that have been coursed through the Center have been included, the total amount is still only around P109 million, “which is still far from the libelous pronouncements being made by PhilHealth.”
Evangelista said the suspension of QCEC’s operation “was based on wrong and unconfirmed information from a yet-unfinished audit, conducted by personnel unqualified to undertake such and therefore unable to make pertinent and sound analyses and conclusions.”
Colombo scholarship grantee: Hurn College of Air Traffic Control, Bournemouth, United Kingdom.
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