WITH the help of its new software system, the Philippine Health Insurance Corporation (PhilHealth) on Friday announced it is now investigating three additional hospitals in Mindanao for allegedly filing fraudulent claims exceeding that of WellMed Dialysis Center.
WellMed Dialysis recently made it to the headlines after supposedly filing at least P800,000 worth of fraudulent claims before PhilHealth. The incident sparked numerous investigations on the operation of PhilHealth and eventual led to changes in its leadership.
In a media forum on Friday, PhilHealth Senior Vice President Rodolfo Del Rosario Jr. disclosed the millions of illegally collected fees by the said medical facilities in Region 12 would make the supposed fraud claims of WellMed Dialysis pale in comparison.
He said the three Level-2 hospitals are now facing possible withdrawal of their accreditation in some operations from PhilHealth and similar charges filed against WellMed.
WellMed sanctions
PhilHealth has slapped WellMed with almost P2 billion worth of fines for violating the National Health Insurance Act as well as several administrative and criminal cases for its alleged fraudulent claims.
Del Rosario said WellMed would also have to pay restitution to PhilHealth.
However, he said both the fine and restitution is still not executory since it could still be appealed by WellMed before the PhilHealth board.
PhilHealth President and CEO Ricardo C. Morales said they are careful in imposing sanctions against the erring medical facilities to avoid disenfranchising patients.
“If they have their accreditation revoked, they could still accept patients. They will only not be able to file claims with PhilHealth,” Morales explained.
MIDAS system
Del Rosario said the three medical facilities were flagged by their Machine Learning Identification, Detection and Analysis System (MIDAS) for claims which are statistically improbable.
He explained MIDAS uses data submitted by PhilHealth-accredited medical facilities and practitioners to detect “sudden spikes in terms of volumes of claims on specific diseases, when there is no epidemic.”
Del Rosario said they are working with the National Bureau of Investigation (NBI) to go after those facilities or personnel who may be involved in illegal activities.
“Our evidence [from MIDAS] is good for administrative cases, but for criminal cases there should be stronger evidence. NBI are the ones working on that,” Del Rosario said.
Since they launched MIDAS in 2018, Del Rosario said it increased the number of their investigation by 300 percent.
PhilHealth currently has 23,000 possible fraud cases.
Of these cases, Del Rosario said about 4,000 are under arbitration after being found with prima facie evidence against the particular PhilHealth-accredited medical facility or practitioner.
Digital future
However, PhilHealth faces the challenge of investigating the said cases due to lack of personnel and resources.
Morales pointed out the large number of the cases shows gaps in their anti-fraud mechanism.
“If it [anti-fraud mechanism] is a net, then it currently has large holes. This means we need a finer net. Automation is supposed to provide that,” Morales said.
Morales said they are now beefing up their information technology capabilities for membership identification, connectivity and bandwidth.
“In the future, if we are successful, all members can transact with PhilHealth using their smartphones. You will know the status of your contribution and hospital near you,” Morales said.
Del Rosario said they are also in the process of hiring additional 128 lawyers since they only have 12 in their legal department.
Image credits: philhealth.gov.ph