THE Philippine Health Insurance Corp. on Thursday announced it was suspending its Interim Reimbursement Mechanism (IRM), which lawmakers in both chambers of Congress focused on this week as they investigated alleged anomalies in the agency.
In a statement, the state insurer said the suspension would give it time to review its overall implementation, amid questions raised in parallel congressional hearings, and vowed ways to make it “more responsive” to the need of members amid the Covid-19 pandemic.
As this developed, senators are lining up questions for beleaguered Health Secretary Francisco Duque III when he finally appears on Tuesday before the ongoing Senate Committee of the Whole inquiry into the reported multibillion-peso corruption at PhilHealth.
This, as Sen. Panfilo Lacson described Secretary Duque as the “big elephant that was not present in the room” at the Senate’s first two hearings of the Committee of the Whole looking into what Lacson described as “PhilHealth’s unbridled corruption.”
Lacson added, “Hopefully we will see him Tuesday,” and stressed that it is “only appropriate that Secretary Duque address the senators’ queries, being the top man at PhilHealth.
For instance, Lacson said senators are keen to know “who was present during the shouting match in their [PhilHealth’s] last board meeting that effectivelytriggered these new controversies?”
Lacson is keen to hear from Duque himself “why has he kept very quiet in spite of all the anomalies being openly discussed with so many unanswered questions involving highly questionable transactions by PhilHealth?”
Lacson likewise listed “highly questionable transactions by PhilHealth in the procurement of IT equipment, IRM funds distribution and manipulation of the agency’s financial statement, which the Commission on Audit has red-flagged on top of recurring disallowances and suspension in billions of pesos year in year out.”
Most important, Lacson wanted to know “what does he [Duque] intend to do or recommend to the President?”
Lack of transparency
In a separate statement, Sen. Juan Edgardo Angara traced to “persistent lack of transparency and accountability” the financial mess at PhilHealth.
He cited the Commission on Audit’s disclaimer of opinion on the fairness of the presentation of PhilHealth’s financial statement due to “questions about the benefits claims expense and doubts about the accuracy of the collections made by the corporation.”
Angara added that COA had noted it could not establish the accuracy of PhilHealth’s restated financial statement for 2017 “because it was not supported with complete and relevant documents.”
Addressing PhilHealth Fund Management Sector SVP Renato Limsiaco Jr. at the Senate’s Committee of the Whole hearing last Tuesday, Angara lamented “the failure of the institution to shape up in spite of the repeated adverse findings issued by COA.”
In effect, he said, the COA has been saying for many years now that PhilHealth has not been transparent because it has understated or overstated income; and the benefit payments are not supported.
If this was done in a private company, the erring officials would have ben fired a long time ago, Angara added.
The senator, meanwhile, welcomed COA’s decision to conduct a special audit on PhilHealth, which he has been pushing for in response to the controversies that emerged in recent months.
He urged COA to include the Interim Reimbursement Mechanism being used by PhilHealth to settle claims on Covid-19 cases by health facilities to determine if the process is fair and aboveboard, recalling that “numerous allegations have been made about how PhilHealth seems to be favoring some facilities over others, including those that do not even cater to Covid-19 patients.”
Fill gaps in IT – Villanueva
Members of the House of Representatives on Thursday asked the national government to now step in so that the much needed upgraded in the insurance agency’s information technology (IT) system will be procured the soonest.
Citizens’ Battle Against Corruption (Cibac) Party List Rep. and Deputy Speaker Bro. Eddie Villanueva said an upgraded IT system will save payments and disbursements of PhilHealth funds at the mercy of “conniving corrupt officials.”
“We demand that those who will be found liable of pocketing public funds must be held accountable and penalized. However, we appeal to the government to intervene, at the same time, in order to pursue the procurement of the needed information technology which was previously stalled after being found to be grossly overpriced,” he added.
“It is apparent from the proceedings of the investigations that an improved IT is very much crucial to deter and prevent fraudulent claims in the future,” Villanueva said in a statement.
“I I think upgrading and capacitating its information technology system is crucial,” he added.
“The government can either direct PhilHealth Board of Directors to procure it now while closely ensuring adherence to procurement laws or let other agencies, like the Procurement System of the DBM, do it for PhilHealth. Unless we institute systemic reforms in PhilHealth now, its funds will always be exposed and vulnerable to fraud and stealing,” added the Cibac lawmaker.
Excess payment
In a separate statement, Marikina Rep. Stella Luz Quimbo, an economist, estimated that the extent of fraud relating to excess pneumonia payments is estimated at P15.4 billion from 2014 to 2018.
“The extent of fund leakages due to fraudulent PhilHealth claims for pneumonia, whether due to ghost claims (claiming against Philhealth for non-existent pneumonia patients) or upcasing (such as claiming for pneumonia for patients with only the common cough and cold), is estimated at 3.6 billion pesos for 2018 [alone],” she said. “This amount, if not lost by PhilHealth, would have been sufficient to fund hospital admissions for PhilHealth’s total projected Covid-19 cases for 2020.”
In 2018, Quimbo said the number of PhilHealth claims for pneumonia reached 757,266, which is 253,382 more than the estimated number of pneumonia patients based on DOH morbidity data.
On average, she said PhiHealth paid P14,445 per claim in 2018, hence, the value of ghost and upcased claims is estimated at P3.6 billion in 2018.
“It’s about time that health insurance professionals manage the fund. We cannot rely on learning by doing when it comes to managing a social health insurance fund that receives subsidies and premium contributions from government employees of close to P100 billion every year. If this does not work, government should begin to consider privatizing the fund management,” she added. Butch Fernandez, Jovee Marie N. Dela Cruz